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
 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. Examples of poor management would include
failure to examine the chest, admission before treatment, failure to order a chest x-ray after
inserting the chest tube and or needle, and long delay in treatment.

In this acute presentation, timing is critically important. An optimal approach would include
completing the above diagnostic and management actions as quickly as possible. 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. Other examples of treatments that
would waste time, 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
 Orientation Feedback for Rheumatoid Arthritis

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 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 in both wrists, 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. Other physical findings are unremarkable. In the absence
of other findings, the patient’s illness, at this point, seems most consistent with rheumatoid
arthritis. While the presence of certain clinical features is helpful in excluding other connective
tissue disease and degenerative joint disease (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 optimal, efficient, and effective approach to diagnosis would include performing an

appropriate physical examination (including extremities, chest, cardiovascular, abdominal, skin,
HEENT, and lymph node examinations). A rheumatoid factor test or a cyclic citrullinated
peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. The
diagnostic workup would also include a complete blood count, arthrocentesis with relevant
synovial fluid studies (cell count, crystals, and bacterial culture), an antinuclear antibody (ANA)
test, and an erythrocyte sedimentation rate or C-reactive protein test. These tests serve to assess
the severity of the disease and consider the likelihood of SLE, gout, an infectious process, or
reactive arthritis. In addition, joint x-rays would provide a baseline assessment.

In adult patients, an optimal approach to treatment would focus on relieving pain, reducing
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. To prevent deformity and loss of joint function, the patient would be advised to exercise
appropriately, or a referral would be made for physical or occupational therapy. A nonsteroidal
anti-inflammatory drug (NSAID) or corticosteroid is considered first-line therapy for relieving
pain and reducing inflammation. Concomitant administration of a disease-modifying
antirheumatic drug (DMARDs), e.g., methotrexate or etanercept, is considered optimal in
preventing or slowing joint damage, and improving joint function. Initial NSAID or
corticosteroid treatment is essential to provide interim symptom relief while the selected
DMARD takes effect.

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

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, anti-single-stranded DNA
Thyroid studies
Urinalysis
Uric acid, serum

Examples of suboptimal management of this case would include delay in diagnosis or treatment,
or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would also be
considered suboptimal management in this case. Although they would temporarily relieve pain
when administered in high doses, there are other agents with fewer toxic side effects that would
be better treatment options. Examples of poor management would include failure to order any
physical examination or failure to treat rheumatoid arthritis.

Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and
add no useful information to that available through history, physical exam, and other relatively
noninvasive laboratory tests include:

Arthroscopy
Synovial biopsy

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.
 Orientation Feedback for Acute Immune Thrombocytopenic Purpura (ITP)

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 5-year-old boy is brought to the emergency department by his mother because of
recurrent nosebleeds. Initially the differential diagnosis is narrow; however, the comprehensive
history broadens the differential. The patient has had recurrent nosebleeds during the past 24
hours. The bleeding stops after applying direct pressure. He also has a red rash and a recent
history of upper respiratory tract infection. The onset of bleeding and a rash, along with the
recent history of upper respiratory tract infection, without a recent history of history of diarrhea
or abdominal pain, suggests the possibility of a coagulation disorder.

Physical examination shows blood oozing slowly from the right naris and a petechial rash on the
face, arms, and legs. The patient is frightened and crying. There is no lymphadenopathy or
splenomegaly. The remainder of the physical examination is unremarkable. The patient's illness,
at this point, would still seem most consistent with a hematologic process. Most cases of
nosebleed last a short time, are self-limited, and require no diagnostic work-up or intervention. In
this case, however, the co-occurrence of bleeding and rash, the recurrent nature of the
nosebleeds, and the antecedent viral illness necessitate further diagnostic evaluation and
appropriate treatment.

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 optimal, efficient, and effective approach would include performing an appropriate physical
(including lymph node, HEENT/neck, chest/lung, cardiovascular, abdominal, and skin or
extremities examinations), controlling the oozing blood by ordering direct pressure to the nose,
and ordering a complete blood count (CBC). Once the low platelet count is discovered and the
peripheral smear reviewed, the diagnosis of acute ITP can be made. In addition, a reticulocyte
count should be ordered to exclude other thrombocytopenic disorders such as thrombotic
thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS).

Since serious bleeding in children with ITP is rare, observation and monitoring of the platelet
count would be acceptable management. Alternatively, administration of intravenous
immunoglobulin (IVIG) is equally acceptable. Other acceptable treatment alternatives include
administration of corticosteroids or administration of IV Rho(D) immune globulin (after
verifying that the patient is Rh positive). Intramuscular injections are not optimal in this case
because of the patient’s low platelet count.

As in many cases, continued monitoring is an important consideration in this case. Regardless of

the ITP treatment option, the patient’s platelet count should be monitored through repeat CBCs.
Note that the benefit of measuring platelet antibodies remains debatable as does performing bone
marrow aspirate/biopsy.

Examples of additional tests and treatments that might be ordered but would be neither useful
nor harmful to the patient management include:

Antibody, antinuclear
Antibody, antiphospholipid
Antibody, hepatitis C
Anticoagulant, lupus, plasma
Polymerase chain reaction, HIV, DNA

Examples of suboptimal management of this case would include delay in ordering the CBC or
failure to treat the nosebleed. Examples of poor management would include failure to order a
CBC in order to identify the thrombocytopenia or failure to monitor the platelet count.

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
 Orientation Feedback for Giardiasis

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 25-year-old man comes to the office because of diarrhea and abdominal cramps.
From the chief complaint, the differential diagnosis is broad; however, the comprehensive
history narrows the differential. The patient was well until 3 weeks previously, when he began to
have four to six loose, watery stools per day. The absence of systemic symptoms such as fever or
malaise, blood in the stool, or tenesmus reduces the likelihood of invasive gastrointestinal
infection or inflammatory bowel disease. Diarrhea lasting 1 to 4 weeks is usually infectious in
origin. There is no history of drug use, recent hospitalizations, or recent use of antibiotics to
suggest Clostridium difficile-induced enterocolitis. The presence of nocturnal symptoms and
weight loss indicates that the problem may be more than a purely functional gastrointestinal
motility disorder. The patient’s recreational pursuit of camping may be of etiologic significance;
there is no history of other infectious exposures.

Physical examination shows no volume depletion. The patient does not appear ill and the
abdomen is soft and nontender. Stool is negative for gross or occult blood, and the remainder of
the physical examination is unremarkable. The patient's illness, at this point, would seem most
consistent with an acute or subacute infectious process.

Most instances of diarrhea are of short duration and are self-limited and require no diagnostic
work-up. In this case, however, the duration of symptoms, the weight loss, and the lack of
response to over-the-counter medications warrant a diagnostic evaluation and appropriate
treatment. In the absence of fever or severe dysentery, antimotility agents can be used for
symptomatic relief pending test results.

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 optimal, efficient, and effective approach would include (1) performing an appropriate
physical that includes abdominal and rectal examinations, (2) ordering diagnostic testing with a
stool culture, and stool Giardia antigen or stool for ova and parasites, and (3) treating with oral
metronidazole after confirming the diagnosis of giardiasis. Monitoring is not important in this
case, although it may be essential in other cases.

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
 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, diagnosing giardiasis with a duodenal aspirate or serum Giardia
antibody without first attempting to identify the organism in the stool, and then treating with
second line antibiotics such as furazolindone, nitazoxanide, or paromomycin.

Examples of suboptimal management of this case would involve admitting the patient to the
hospital or delay in diagnosis or treatment of the giardiasis. Examples of poor management
would include failure to order any physical examination or failure to treat giardiasis.

Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and
add no useful information to that available through history, physical exam, and other relatively
noninvasive laboratory tests include:

Upper Endoscopy
Colonoscopy
Barium studies
 Orientation Feedback for Ascending Aortic Dissection

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 woman comes to the emergency department complaining 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 coming to the
hospital. 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 mild 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 left sternal
border. HEENT 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 optimal, efficient, and effective approach would include performing a targeted physical
examination (including cardiovascular and chest/lung examinations), ordering a 12-lead
electrocardiogram and a portable chest x-ray. Stabilizing the patient with intravenous (IV) beta
blocker or an IV antihypertensive agent administration to reduce blood pressure, and IV narcotic
analgesic administration to alleviate pain is important. The patient’s cardiovascular status should
be monitored with a cardiac monitor or by ordering repeat vital signs. Some measure of oxygen
saturation is also indicated.

Once stable, some form of chest imaging that would reveal an aortic dissection (including CT of
the chest with contrast, CT of the chest without contrast, echocardiogram, transesophageal
echocardiogram (TEE), or MRI of the chest) is needed. 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 levels, a complete blood
count (CBC) to look for signs of anemia and infection, serum creatine phosphokinase or serum
troponin I (cardiac enzymes) to rule out myocardial compromise, a d-Dimer to rule out a
pulmonary embolus, and a type and crossmatch blood. Some measure of oxygen saturation is
also indicated.

Once the ascending aortic dissection is discovered and aortic root involvement confirmed,
optimal treatment should include either open heart surgery, thoracotomy or thoracic surgery, or
general surgery consult.

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

Examples of additional tests, treatments, 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, 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, administering an IV
antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in
diagnosis or treatment. It would be suboptimal to order anything unnecessary that would waste
time, even if the test or procedure is not invasive or risky, e.g. lung scan.

Examples of poor management would include failure to order any physical examination, failure
to order an imaging study that would reveal the dissection, failure to administer an
antihypertensive agent, or failure to order surgical intervention.

Examples of invasive and 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, 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