01-04-2008, 06:19 AM
CASE 1 : CARDIAC TAMPONADE
1) Feedback: The patient is hemodynamically unstable with initial vital signs showing tachycardia, tachypnea and hypotension. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor blood pressure, heart rate and oxygenation.
Beck's triad
a)Decrease in systemic arterial pressure
b)Elevated central venous pressure
c)Small, quiet heart
ORDER
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Oxygen
Intravenous access
Normal saline, 0.9% NaCl
Elevate foot of bed
2)Feedback: Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. A lengthy examination should not be initially performed in a hemodynamically unstable patient as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient.
Important aspects of the examination to focus on in this patient include:
General:
Responsiveness, amount of distress, stupor
Heart:
Soft heart sounds, distended neck veins, pulsus paradoxus (Cardiac tamponade)
Harsh systolic murmur, upper extremity hypertension, diminshed femoral pulses (Aortic injury)
Lungs:
Reduced breath sounds, hyperresonance to percussion (Tension pneumothorax)
Reduced breath sounds, dullness to percussion (Hemothorax)
Reduced breath sounds, moist rales, chest wall bruising (Pulmonary contusion)
3) Feedback: The physical examination reveals soft heart sounds, weak pulse, jugular venous distension and pulsus paradoxus. These findings strongly point to the diagnosis of cardiac tamponade.
Treatment for cardiac tamponade should be instituted based on the physical examination and should not be delayed for results of any laboratory or imaging studies. Therefore, it is imperative to order pericardiocentesis at this point. A surgery consult is automatically ordered when you order pericardiocentesis. A reason for consultation is requested on the USMLE CCS cases, but is not graded; therefore it is not requested in these case simulations. A reasonable entry might include "patient with signs of cardiac tamponade requiring urgent pericardiocentesis".
Additional studies to help confirm the diagnosis and rule out other diagnoses should also be ordered as shown below.
· Echocardiography - gold standard for diagnosis of cardiac tamponade.
· Chest x-ray - may show enlarged cardiac silhouette
· ECG - may show low-voltage QRS complexes, ST segment elevation, or PR segment depression. Electrical alternans is pathognomonic of cardiac tamponade and is characterized by alternating levels of ECG voltage of the P wave, QRS complex, and T waves.
Pain management is also a consideration but not weighted heavily in the time frame of this case.
Additional orders (ESR, thyroid function tests, ANA, Rheumatoid Factor, PPD, blood cultures, viral titers, and pericardial fluid analysis and cultures) are often ordered when the cause of pericardial tamponade is not known. However, in this case, acute pericardial tamponade is directly related to trauma therefore these additional studies are not necessary.
ORDER
Pericardiocentesis
Consult, surgery, thoracic
ECG, 12 lead
Chest X-ray, portable
Echocardiography
Morphine, intravenous, one time/bolus
4) Feedback: Once initial diagnosis and treatment has been instituted, a more thorough physical examination can be performed to look for additional injuries and guide further management.
Examination
Skin
HEENT/Neck
Abdomen
Genitalia
Rectal
Extremities/Spine
Neuro/Psych
5) Feedback: The following routine trauma orders following a motor vehicle accident are not necessarily directly related to the management of cardiac tamponade and therefore are not weighted heavily in scoring. They may earn a small amount of points and are therefore included in the management of this case.
· Routine orders for monitoring bleeding and detecting electrolyte imbalances - CBC, BMP, PT/PTT, type and crossmatch blood
· Blunt chest/abdominal trauma orders - Cardiac enzymes (damage to the heart), amylase (damage to the pancreas)
· Routine X-rays following MVA: Chest x-ray (previously ordered), pelvis x-ray and cervical spine x-rays.
· Routine toxicology screening in MVA: Blood alcohol and toxicology screen
ORDER
CBC with differential
BMP - Basic Metabolic Profile
PT/PTT
Cardiac enzymes, serum
Amylase, serum
Cervical spine films, portable
Pelvic x-ray, portable
Alcohol, blood
Toxicology screen, urine
Type and crossmatch, blood
6) Feedback: Once all relevant examinations have been performed and orders have been placed, the clock can be advanced to obtain results. For emergency cases, the clock should be advanced "with the next available result" as management may change with individual results.
7) Feedback: Following pericardiocentesis, it is important to confirm relief of the cardiac tamponade with a repeat chest x-ray and echocardiography. In addition, vital signs must be monitored regularly to ensure improvement following treatment.
ORDER
Chest X-ray, portable
Echocardiography
Vital signs
8) Feedback: After placing monitoring orders following pericardiocentesis, the clock can be advanced "with the next available result" to reveal results of the vital signs and check for patient updates.9)Feedback: Following pericardiocentesis, the patient should be monitored in the ICU. However, transferring the patient may be beyond the time frame of this case, therefore it is not weighted heavily in scoring.
The patient is transferred to the ICU. 10) Feedback: The clock can be advanced "with the next available result" to reveal additional results and check for patient updates. 11) Feedback: Although not heavily weighted, since the patient was not wearing a selt belt, it is advisable to counsel him to wear a selt belt once he has recovered. SEQUENCING Orders Blood pressure monitor, cardiac monitor, oxygen, pulse oximetry, elevate foot of bed, intravenous access, normal saline 0.9% NaCl
Exam General, heart, lungs
Orders Pericardiocentesis, consult thoracic surgery, chest x-ray, ECG, echocardiography, morphine
Exam Additional: skin, HEENT, abdomen, extremities + others
Orders CBC, BMP, PT/PTT, cardiac enzymes, amylase, type & crossmatch blood, alcohol blood, cervical spine x-rays, pelvis x-ray, toxicology urine
Clock Advance to pericardiocentesis
Orders Chest x-ray, echocardiography, vital signs
Clock Advance to vital signs
Location Transfer to ICU
Clock Advance to additional results and case end
End Orders Advise patient drive with seat belt
Case 23: Complaint: Fatigue Specialty: Medicine Topic: Hematology Setting: Office
Case Summary
· 58-year-old man with fatigue and weakness for 3 months.
· Vital signs are unremarkable.
· History reveals tongue pain, mild confusion, memory loss, poor diet, smoker of 1 pack per day for 35 years, heavy alcohol use.
· Examination shows pale conjunctiva, tongue enlarged and reddened, mild hepatosplenomegaly, mildly diminshed deep tendon reflexes.
· Laboratory studies show abnormal LFT (elevated AST/ALT with AST 3 times greater than ALT, low albumin), CBC with macrocytic anemia and hypersegmented neutrophils, low vitamin B12, low folic acid.
· Abdominal ultrasound reveals fatty liver.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: HEENT, neuro · CBC · LFT · Vitamin B12, serum · Folic acid, serum · Folic acid, erythrocyte · · Exam: complete · BMP · TSH · Glucose, fasting · Reticulocyte count · Ferritin · Iron & TIBC · PT/PTT · Hep B surface antigen · Hep C antibody · Abdominal ultrasound
THERAPY · Advise, no smoking · Advise, no alcohol · Alcoholics Anonymous · Vitamin B12, therapy · Folic acid, therapy · Thiamine · Consult, dietary · Reassure · Counsel
MONITORING · CBC
LOCATION · Office
TIMING · Do not delay CBC. · Order CBC first, then follow with vitamin B12 and folic acid levels. · Do not delay counseling to stop smoking, stop alcohol use, and improve nutrition.
SEQUENCING Exam Complete
Orders CBC, BMP, LFT, TSH, glucose fasting, advise no smoking, advise no alcohol, Alcoholics Anonymous
Clock Advance clock to reschedule patient when all results are reported
Orders Reticulocyte count, vitamin B12 serum, folic acid serum, folic acid eryhtrocyte, ferritin, iron & TIBC, PT/PTT, hep B surface antigen, hep C antibody, abdominal ultrasound
Clock Advance clock to reschedule patient when all results are reported
Orders Vitamin B12 therapy, folic acid therpy, thiamine, consult dietary, reassure, counsel
Clock Advance to case end
End Orders CBC
Feedback1): In an office based case with a patient who is hemodynamically stable, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
Skin:
Jaundice - Liver disease
HEENT:
Mucosal and conjunctival pallor - Anemia
Glossitis - Folate or vitamin B12 deficiency
Goiter - Thyroid abnormalities
Vision abnormalities - Diabetes
Lymph nodes:
Enlarged lymph nodes - Lymphoma, metastatic disease
Abdomen:
Hepatomegaly - Liver disease
Abdominal mass - Cancer
Rectal:
Occult blood positive - Chronic blood loss, Colon cancer
Hard, irregular prostate - Prostate cancer
Neuro/Psych:
Gait disturbance, loss of reflexes and mental status changes - Vitamin B12 deficiency
Feedback2): On physical examination, the patient has signs of anemia. A CBC should be ordered first in the work-up of anemia.:
In addition, it is important to rule out other differential diagnoses of fatigue, such as thyroid abnormalities (TSH), diabetes (fasting glucose), electrolyte abnormalities (BMP), and liver disease from alcohol use (LFT).
The patient is noted to smoke and drink alcohol in the initial history and it is imperative to advise him to stop smoking and drinking alcohol (Alcoholics anonymous, advise patient no alcohol and advise patient no smoking)
ORDER
CBC with differential
BMP - Basic Metabolic Profile
LFT - Liver function profile
Glucose, serum, fasting
TSH, serum, ultrasensitive
Alcoholics anonymous
Advise patient, no alcohol 5 minutes Advise patient, no smoking 5 minutes
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 11:00). Since appointments can only be scheduled Mon-Fri 9-5 in the office setting, the next available appointment is Day 4 @ 09:00 (Mon).
The patient will be rescheduled for an appointment on Day 4 @ 09:00. This will advance the clock to Day 4 @ 09:00.
Feedback4): CBC reveals megaloblastic anemia. Additional work-up should include:
· Vitamin B12, serum - low level indicates Vitamin B12 deficiency; keep in mind false positive may be seen in malabsorption syndrome and hypothyroidism
· Folic acid, serum - only indicates negative folate balance, therefore also need RBC folate to determine true deficiency
· Folic acid, erythrocyte (RBC Folate) - Low when body stores are depleted. Alone not reliable, but must be correlated with serum B12 and folate.
· Reticulocyte count - indicates level of RBC production and may be the first indication of successful treatment
· Ferritin & Iron studies - Up to 1/3 of patients with Vitamin B12 and Folate deficiency also have Iron deficiency.
In addition, liver function tests show aspartate (AST) two to three times higher than the alanine aminotransferase (ALT) and low albumin consistent with alcoholic hepatitis. Serum glucose is often low in the alcoholic patient secondary to the attendant malnutrition and cirrhosis and inhibition by alcohol of gluconeogenesis. Additional work-up of alcoholic hepatitis should be ordered:
· Hepatitis B & C serology - essential in assessment to rule out contributing viral hepatitis.
· PT/PTT - test of hepatic synthetic function and can be used to assess severity
· Abdominal ultrasound - can detect fatty infiltration and may detect cirrhosis
ORDER
Reticulocyte count, blood
Vitamin B12, serum
Folic acid, serum
Folic acid, erythrocyte
Ferritin, serum
Iron and total iron binding capacity, serum
PT/PTT
Hepatitis B surface antigen, serum
Hepatitis C antibody, serum
Abdominal ultrasound
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after Day 7 @ 9:00).
Feedback6): Treatment for Vitamin B12 and folate deficiency should include replacement of each and also address possible thiamine deficiency. In addition, general counseling and nutrition replacement (dietary consult) should accompany alcohol abstinence (previously ordered) for treatment of alcoholic hepatitis.
ORDER
Vitamin B12, therapy, oral continuous
Folic acid, therapy, oral continuous
Thiamine, oral, continuousConsult, dietary Day 8 @ 10:00 Reassure patient 5 minutes Counsel patient 5 minutes
Feedback7): The patient should be rescheduled in 1-2 weeks for a check of improvement in CBC and symptoms.
Feedback8): Weekly CBC should be monitored for improvement, however it may not be necessary in the time frame of this case.
ORDER
CBC
Case 28: Complaint: Fatigue and Irritability Specialty: Pediatrics Topic: Hematology Setting: Office
Case Summary
· 27-month-old boy with fatigue and irritability for 2 months. · Vital signs are unremarkable. · History reveals child is a fussy eater, drinking mainly milk and juices and refusing to eat meat and vegetables. · Physical examination reveals pallor. · Laboratory studies show CBC with microcytic anemia and basophilic stippling of erythrocytes, decreased ferritin & serum iron, and blood lead level of 52 mcg/dL.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: skin · CBC · Ferritin · Lead, blood quantitative · Exam: additional · Reticulocyte count · Iron and total iron-binding capacity
THERAPY · Iron sulfate · Lead chelation - succimer · Consult, dietary · Lead abatement agency · Diet, high iron · Iron-enriched infant formula · Advise, limit intake of cow's milk · Reassure · Counsel patient/family
MONITORING · CBC · Lead, blood quantitative · Ferritin
LOCATION · Office
TIMING · Do not delay CBC. · Order CBC first, then ferritin and lead levels.
SEQUENCING Exam Complete
Orders CBC
Clock Advance clock to results of CBC
Orders Ferritin, iron & TIBC, lead blood, reticulocyte count
Clock Advance clock to reschedule patient when all results are reported
Orders Iron sulfate, lead chelation - succimer, iron-enriched infant formula, lead abatement agency, diet high iron, advise limit intake of cow's milk, reassure, consult dietary, counsel
Clock Reschedule patient depending on elevated lead levels (2 days if >50)
Orders Lead blood
Clock Avance clock to any additional updates.
End Orders CBC, lead, ferritin
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
Skin:
Pallor - Anemia
HEENT:
Pale conjunctiva - Anemia
Glossitis, angular stomatitis - Vitamin deficiency, anemia
Heart:
Murmur - Hemolytic anemia
Rectal exam:
Occult blood positive - Chronic blood loss
The following examinations will be performed. Examinations you requested will be used in assessing your score, but results will not be reported. Only results for the following examinations will be reported.
Examination
Time
General appearance
Skin
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Rectal
Extremities/Spine
This will advance the clock to: Day 1 @ 11:11
Feedback2): The work-up of pallor in an infant should begin with a complete blood count. This will confirm the presence of anemia and can provide clues to the cause. Once anemia is confirmed, then a work-up of the cause of anemia should be performed.
Feedback3): The clock should be advanced "with the next available result" to advance to the CBC results.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 10:11.
Feedback4): The differential causes of microcytic anemia include: Ferritin Iron, serum TIBC RBC RDW Lead, blood FEP
Chronic disease N to H L L N, L, H N to H N N, H
Lead poisoning N N N N N, H H H
Iron deficiency L L H L H N N, H
Sideroblastic H H L N H N N
Thallasemia N to H N N H N N N
L = Low N = Normal H = HighLaboratory studies that can be useful to help differentiate the cause of microcytic anemia include:· CBC - Low Hemoglobin, Low MCV confirms microcytic anemia. o Hypochromasia, poikilocytes seen in Iron deficiency. o Basophilic stippling seen in lead poisoning. o RDW increased in Iron deficiency, normal in thallasemia. o RBC high in thallasemia, low in iron deficiency · Ferritin, serum - Decreased level most useful for diagnosing iron deficiency · Serum Iron & TIBC - Additional studies to confirm iron deficiency · Blood lead, quantitative - Used as screening for lead poisoning · Free erythrocyte protoporphyrin (FEP) - May be increased in lead poisoning, iron deficiency and chronic disease, not specific. · Hemoglobin electrophoresis - should be ordered only if other tests are negative. o High Hemoglobin A2 in Beta-thallasemia. o Alpha-thallasemia is a diagnosis of exclusion when hypochromic microcytic anemia seen in familial form with normal iron studies, lead studies, and hemoglobin electrophoresis.
ORDER REPORT TIME
Ferritin, serum Day 2 @ 10:11
Iron and total iron binding capacity, serum Day 2 @ 10:11
Lead, blood, quantitative Day 2 @ 10:11
Reticulocyte count, blood Day 2 @ 10:11
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after Day 2 @ 10:11). Although some treatment orders can be started, it is best to obtain a proper diagnosis of the anemia prior to initiating treatment. The patient will be rescheduled for an appointment on Day 2 @ 11:00. This will advance the clock to Day 2 @ 11:00.
Feedback6): Results show iron deficiency anemia and lead poisoning. Treatment of iron deficiency anemia includes:· Oral medications - Iron sulfate. Multivitamins with iron are inadequate for treatment. · Diet modifications to increase iron intake - Diet high iron, Iron enriched infant formula, Avoid cow's milk and consult dietary · Monitoring of improvement - Symptoms improve in 3-4 days, CBC in 1 month, Ferritin in 3 months Treatment of Lead poisoning depends on the blood lead levels: BLL Action <10 No action needed10-19 Repeat blood test within 3 months, Counsel20-44 Repeat blood test within 1 month, Counsel, refer to lead abatement agency (LAA)45-69 Repeat blood test within 1-2 days, Counsel, referral LAA, oral chelation therapy (succimer)>70 Hospitalization, stat venous blood test, education, referral LAA, IV chelation therapy (EDTA)
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Lead chelation - succimer
Iron sulfate, oral, continuous
Iron-enriched infant formula
Diet, high iron
Lead abatement agency
Consult, dietary Day 3 @ 11:00
Counsel patient/family 5 minutes
Advise patient, limit cow's milk intake 5 minutes
Reassure patient 5 minutes
Counseling orders must be ordered and performed separately on the USMLE CCS cases, however in this case simulation you may place multiple counseling orders simultaneously. Counseling orders will advance the clock to Day 2 @ 11:15.
Feedback7): For lead levels greater than 50, the patient should be rescheduled in 1-2 days for repeat blood lead level.
Feedback8): For initial lead levels greater then 50, repeat blood levels should be measured in 1-2 days to ensure improvement with therapy.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Lead, blood, quantitative Day 5 @ 09:00
Feedback9): At this point, the patient can be rescheduled in about 1-4 weeks for repeat CBC and lead levels.
The patient will be rescheduled for Day 30 @ 09:00. This will advance the clock.
Feedback9): Normal response to treatment for iron deficiency anemia:
1-2 days: Improvement in symptoms such as appetite and irritability
4-30 days: Improvement in hemoglobin levels (CBC should return to normal by 1 month)
1-3 months: Repletion of iron stores (Ferritin should return to normal by 3 months).
Continue oral iron therapy for 8 weeks after hemoglobin level returns to normal.
ORDER ORDER TIME
CBC with differential 1 week
Ferritin, serum 2 months
Lead, blood, quantitative 1 month
Case 1: Complaint: Motor vehicle accident
Specialty: Surgery Topic: Trauma Setting: Emergency Department
Case Summary
· 33-year-old man with chest pain and respiratory distress following a motor vehicle accident.
· Vital signs show tachycardia (118 beats/min), tachypnea (32 breaths/min), and hypotension (100/60 mm Hg).
· History reveals he was the unrestrained driver and his chest hit the steering wheel. He did not hit his head and there was no loss of consciousness. He was initially alert and responsive and then became dyspneic, agitated, and restless in the ambulance prior to arrival in the emergency department.
· Examination reveals soft heart sounds, weak central and peripheral pulse, jugular venous distension, and pulsus paradoxus.
· ECG reveals electrical alternans; chest x-ray shows enlarged cardiac silhouette; echocardiography reveals cardiac tamponade.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: general, lungs, heart· Chest x-ray, portable· Echocardiography· ECG, 12 lead · Exam: additional · CBC · BMP · PT/PTT · Cardiac enzymes · Amylase · Cervical spine x-ray · Pelvis x-ray · Alcohol, blood · Toxicology screen, urine
THERAPY · Pericardiocentesis (Consult thoracic surgery automatically ordered)· Oxygen · Intravenous access · Normal saline, 0.9% NaCl · Elevate foot of bed · Morphine, intravenous, one-time/bolus · Type and crossmatch, blood · Advise patient, drive with seat belt
MONITORING · Blood pressure monitor, continuous · Cardiac monitor · Pulse oximetry · Echocardiography · Chest x-ray, portable · Vital signs
LOCATION · Emergency department; transfer to ICU for monitoring after pericardiocentesis.
TIMING · Monitoring orders do not take time off the clock and should be ordered prior to any physical exam. · Do not delay cardiac exam. · Order for pericardiocentesis should be made on results of the cardiac exam and should not be delayed for results of chest x-ray or echocardiogram.
SEQUENCING Orders Blood pressure monitor, cardiac monitor, oxygen, pulse oximetry, elevate foot of bed, intravenous access, normal saline 0.9% NaCl
Exam General, heart, lungs
Orders Pericardiocentesis, consult thoracic surgery, chest x-ray, ECG, echocardiography, morphine
Exam Additional: skin, HEENT, abdomen, extremities + others
Orders CBC, BMP, PT/PTT, cardiac enzymes, amylase, type & crossmatch blood, alcohol blood, cervical spine x-rays, pelvis x-ray, toxicology urine
Clock Advance to pericardiocentesis
Orders Chest x-ray, echocardiography, vital signs
Clock Advance to vital signs
Location Transfer to ICU
Clock Advance to additional results and case end
End Orders Advise patient drive with seat belt
Case 2: Complaint: Fatigue
Specialty: Surgery Topic: Gastroenterology Setting: Office
Case Summary
· 66-year-old man with fatigue and constipation for 4 months.
· Vital signs are unremarkable.
· History reveals occasional left lower quadrant abdominal pain, 9-kg (20-lb) weight loss, smoking 1 pack cigarettes a day for 30 years.
· Examination shows occult blood positive.
· CBC reveals microcytic anemia; colonoscopy reveals colon adenocarcinoma.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: rectal, HEENT, lymph nodes· CBC · Ferritin · CEA · Colonoscopy · Exam: additional +/- complete· BMP · TSH · Glucose fasting · LFT · Urinalysis · Iron and TIBC · Abdominal CAT scan · Chest CT · Bone scan · ECG · PT/PTT
THERAPY · Advise, no smoking · Advise, cancer diagnosis · Colectomy · Consult, general surgery · Iron sulfate · Reassure · Type and crossmatch, blood
MONITORING · CBC · CEA · Ferritin
LOCATION · Office
TIMING · Do not delay rectal exam or colonoscopy. · Order CBC first, then iron studies, then iron sulfate.
SEQUENCING Exam Rectal, HEENT, heart, abdomen, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, LFT, urinalysis, colonoscopy, advise no smoking
Clock Advance clock to reschedule patient when all results are reported
Orders Ferritin, iron & TIBC, CEA, abdominal CAT scan, chest CT scan, bone scan, advise cancer diagnosis, reassure
Clock Advance clock to reschedule patient when all results are reported
Orders Colectomy, consult general surgery, iron sulfate, ECG, PT/PTT, type and crossmatch blood
Clock Advance to case end
End Orders CBC, CEA, ferritin
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
HEENT:
Enlarged thyroid - Thyroid dysfunction
Vision abnormalities - Diabetes
Pale conjunctiva - Anemia
Heart:
Murmur - Hemolytic anemia
Abdomen:
Abdominal mass - Renal cancer
Rectal exam:
Occult blood positive - Chronic blood loss, colon cancer
Hard, irregular prostate - Prostate cancer
Lymph nodes:
Enlarged - Metastatic cancer, lymphoma
Examination
General appearance
Skin
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Rectal
Extremities/Spine
Neuro/Psych
Feedback2): On physical examination, the patient is fecal occult blood positive. Colonoscopy is the general standard for work-up of fecal occult blood positive stools. If colonoscopy is negative, EGD can be considered or both may be ordered simulataneously.
In addition to colonoscopy, it is important to rule out other differential diagnoses, such as
· Anemia (CBC)
· Thyroid abnormalities (TSH)
· Diabetes (fasting glucose)
· Electrolyte abnormalities (BMP)
· Renal disease (Urinalysis)
· Liver disease (LFT)
The patient is noted to smoke in the initial history and it is imperative to advise all patients to stop smoking.
ORDER
CBC with differential
BMP - Basic Metabolic Profile
Urinalysis
LFT - Liver function profile
Glucose, serum, fasting
TSH, serum, ultrasensitive
Colonoscopy
Advise patient, no smoking
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 11:15).
Feedback4): Results show the patient has a colon adenocarcinoma and microcytic anemia. Important tests to consider at this point include:· Ferritin, Iron & TIBC - To confirm the microcytic anemia is sceondary to iron loss from chronic blood loss. · CEA - levels can be useful for prognosis and monitoring postoperative course in colon cancer. · Abdominal CAT scan, Chest CT (or chest x-ray), Bone scan - Evaluation for metastatic disease · Appropriate counseling orders Referral to a specialist is more appropriate once clinical staging of the tumor is better known. Surgery is generally the treatment of choice, however adjuvant therapy may be used and stage IV disease is usually treated with chemotherapy.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Ferritin, serum Day 4 @ 11:00
Iron and total iron binding capacity, serum Day 4 @ 11:00
CEA, serum Day 5 @ 11:00
Abdominal CAT scan Day 4 @ 11:00
Chest CT scan Day 4 @ 11:00
Bone scan Day 4 @ 11:00
Advise patient, cancer diagnosis 5 minutes
Reassure patient 5 minutes
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after day 5 @ 11:00). Since office hours are Mon-Fri 9-5, the next available appointment is Day 7 @ 9:00.
Feedback6): The first-line curative treatment for colorectal carcinoma is surgery. Adjuvant chemo/radiation therapy is often used for higher stage tumors once pathologic staging is determined following resection. Routine pre-operative orders (ECG, PT/PTT, Type and crossmatch) may generate a small amount of points. In addition, treatment of iron deficiency anemia with iron sulfate should be started.
ORDER REPORT TIME
Colectomy, by laparotomy Day 8 @ 9:00
ECG, 12 lead Day 7 @ 11:00
PT/PTT Day 7 @ 9:30
Type and crossmatch, blood Day 7 @ 15:00
Consult, general surgery Day 7 @ 10:00
Iron sulfate, oral, continuous
Feedback7): The clock should be advanced to the colectomy procedure.
Feedback8): Important orders to monitor in this patient, which may generate a small amount of points include:
· CBC - should return to normal within 1 month.
· Ferritin - should return to normal within 3 months.
· CEA - levels usually return to normal by 6 weeks following resection.
Case 3: Complaint: Abdominal pain Specialty: Obstetrics & Gynecology Topic: Obstetrics Setting: Emergency Department
Case Summary
· 19-year-old woman with abdominal pain for 6 hours.
· Vital signs show tachycardia (106 beats/min), hypotension (100/60 mm Hg), low-grade fever (38.2°C, 100.8°F).
· History shows pain is sharp, constant, and focused predominately in the right lower quadrant. History is also significant for 6 weeks amenorrhea, vaginal spotting, sexual activity with three men, occasional use of condoms, and previous treatment for Chlamydia.
· Examination reveals lower abdominal tenderness, closed cervical os, cervical excitation present and right adnexal mass with tenderness.
· Laboratory studies reveal positive urine HCG test.
· Imaging with transvaginal ultrasound shows a complex right adnexal cyst.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: genitals, abdomen · HCG, beta, urine, qualitative · Transvaginal ultrasound · Exam: lungs, heart · CBC · BMP · PT/PTT · HCG, beta, serum, quantitative
THERAPY · Laparotomy · Normal saline, 0.9% NaCl · Intravenous access · Oxygen · Consult, obstetrics & gynecology · Elevate foot of bed · Morphine, intravenous, one-time/bolus · RhoGAM · Type and crossmatch, blood · Advise patient, safe sex techniques
MONITORING · Blood pressure monitor, continuous · Cardiac monitor · Pulse oximetry · CBC
LOCATION · Emergency department · Patient should be taken directly to surgery.
TIMING · Emergency monitoring orders do not take time off the clock and should be ordered prior to any physical exam. · Do not delay abdominal and genital exam. · Urine HCG test should be ordered immediately following exam. · Order for laparotomy should be made immediately after HCG result as patient is hemodynamically unstable. It should not be delayed for results of transvaginal ultrasound.
SEQUENCING Orders Blood pressure monitor, cardiac monitor, pulse oximetry, oxygen, intravenous access, normal saline, elevate foot of bed
Exam Abdomen, genitalia + general, heart, lungs
Orders HCG urine, morphine
Clock Advance to HCG results
Orders Laparotomy, consult OB/GYN, transvaginal ultrasound, type & crossmatch blood, HCG serum quantitative, CBC, BMP, PT/PTT
Clock Advance to laparotomy and case end
End Orders CBC, RhoGAM; advise patient safe sex techniques
Feedback1): The patient is hemodynamically unstable with initial vital signs showing tachycardia and hypotension. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor blood pressure, heart rate and oxygenation.
ORDER
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Oxygen
Intravenous access
Normal saline, 0.9% NaCl, Intravenous
Elevate foot of bed
Feedback2): Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. In addition, examination of the abdomen and genitalia are critical in a young woman with abdominal pain. A complete physical examination should not be initially performed as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient. Important aspects of the examination to note in this patient include:General: Distress and pallor may indicate blood lossHeart: Tachycardia and hypotension - Shock due to ruptured ectopicAbdomen: Periumbilical or right lower quadrant tenderness - Acute appendicitis.Fetal heart auscultationGenitalia: Large amount of blood loss and open cervical os - Spontaneous abortionAdnexal tenderness and cervical excitation - Ectopic pregnancyVaginal dischage, tender adnexal mass, cervical excitation - Pelvic inflammatory disease
Examination Time
General appearance 1 min
Chest/Lung 1 min
Heart/Cardiovascular 1 min
Abdomen 1 min
Genitalia 2 min
Feedback3): In a young woman with acute abdominal pain, amenorrhea for 6 weeks and intermittent vaginal bleeding, a pregnancy test is a crucial to initially differentiate between various differential diagnoses.
Pregnancy-related: Ectopic pregnancy, spontaneous abortion
Non-pregnancy related: Pelvic inflammatory disease, endometriosis, dysfunctional uterine bleeding, or acute appendicitis.
In addition, pain relief should be considered early, however in the time frame of this case, analgesia is not weighted heavily in scoring.
ORDER
HCG, beta, urine, qualitative
Morphine, intravenous, one time/bolus
Feedback4): For emergency cases, the clock should be advanced "with the next available result" as the result of the HCG test is critical in further management. Alternatively, you may chose to advance the clock 5 minutes by performing additional physical examinations instead of using the obtain results button (not shown here).
Feedback5): In a hemodynamically unstable patient with a positive pregnancy test and signs of ectopic pregnancy, laparotomy should be immediately ordered without waiting for results of a transvaginal ultrasound. Laparoscopy is a reasonable alternative and is considered safer, but will require a longer wait time. If the patient was hemodynamically stable, a transvaginal ultrasound may help differentiate between ectopic pregnancy and spontaneous abortion to help guide further management.
In addition to laparotomy, additional orders to consider include:
Transvaginal ultrasound - to evaluate adnexal mass and presence of intrauterine pregnancy
Obstetrics/gynecology consultation
CBC - leukocytosis may be seen in ectopic pregnancy, low hemoglobin in blood loss
BMP, PT/PTT and type & crossmatch blood - Routine pre-op orders
Serum HCG - Serial measurements after surgery to ensure complete removal.
ORDER
Laparotomy Consult, obstetrics/gynecology
Transvaginal ultrasound
Type and crossmatch, blood
HCG, beta, serum, quantitative
CBC with differential
BMP - Basic Metabolic Profile
Feedback6): Once all relevant orders are placed, the clock can be advanced to obtain results. For emergency cases, the clock should be advanced "with the next available result" as management may change with individual results. Alternatively, it is also acceptable to initially advance the clock by performing additional physical examinations, not shown in this management strategy.
Feedback7): Although end case orders may not be necessary in the time frame of this case, the following additional orders should be considered as important in the management of ectopic pregnancy and may generate some additional points.
CBC should be monitored to determine the need for transfusion.
Rhogam is normally administered to Rh negative patients within 48 hours to prevent sensitization.
The patient should be counseled about safe sex techniques once recovered.
ORDER
CBC with differential Rhogam, intramuscular, one time/bolus Advise patient, safe sex techniques
Case 4: Complaint: Back pain Specialty: Medicine Topic: Nephrology Setting: Office
Case Summary
· 28-year-old man with painful urination and low back pain.
· Vital signs show elevated temperature (38.0°C, 100.4°F).
· History reveals sharp and severe pain during urination, increased urinary frequency, nocturia, chills, and perineal pain.
· Examination shows tender swollen prostate.
· Laboratory studies show urinalysis positive for blood, nitrite, leukocyte esterase, leukocytes, and bacteria. Urine Gram stain positive for gram-negative rods. Urine culture positive for Escherichia coli. CBC with elevated WBC count.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: rectal · Urinalysis · Urine Gram stain · Urine culture · Exam: general, lungs, heart, genitalia · CBC · Blood culture
THERAPY · Ciprofloxacin/TMP-SMZ· Acetaminophen · Colace · Reassure · Counsel patient/family
MONITORING · Not important for this case
LOCATION · Office
TIMING · Do not delay prostate exam or ciprofloxacin. · Examine results of urine studies at the initial visit.
SEQUENCING Exam General, abdomen, genitalia, rectal +/- complete
Orders Urinalysis, urine Gram stain, urine culture
Clock Advance clock to results of urinalysis and Gram stain
Orders CBC, Blood culture, ciprofloxacin, acetaminophen, colace, reassure, counsel
Clock Advance clock to additional results and patient update
End Orders None
Feedback1): In the office setting with a patient not in acute distress, it is appropriate to begin management with the physical examination. Although a complete physical exam would be optional since the patient is hemodynamically stable, it is more appropriate to narrow and focus the physical examination.
Important aspects of the physical exam include:
Genitalia:
Urethral discharge for culture
Rectal:
Tender, swollen prostate - prostatitis
Hard & irregular prostate - cancer
Fluctuant prostate - prostatic abscess
Examination
General appearance
Skin
Lymph nodes
Chest/Lung
Heart/Cardiovascular
Abdomen
Genitalia
Rectal
Feedback2): Important orders to consider in this patient include: Urinalysis:Leukocyte esterase - Increased (UTI, Gonorrhea or Chlamydia, Prostatitis), Normal (Renal calculi)Blood - Increased (Renal calculi, UTI)White blood cells - same as leukocyte esteraseBacteria - Increased (UTI, Prostatitis), Normal (Gonorrhea or chlamydia, Renal calculi)Urine culture
ositive (UTI, Prostatitis), Negative (Gonorrhea & Chlamydia, Renal calculi) Note: DO NOT ORDER PROSTATIC MASSAGE as prostatic massage may lead to bacteremia in acute bacterial prostatitis.
ORDER REPORT TIME
Urinalysis Day 1 @ 13:40
Urine culture Day 2 @ 13:10
Urine gram stain Day 1 @ 13:30
Feedback3): The clock should be advanced "with the next available result" as the results of the urinalysis and gram stain will help guide further management. It is also reasonable to advance the clock directly to 13:40 or to initially advance the clock by performing additional physical examinations (not shown here).
Feedback4): Acute bacterial prostatitis can be diagnosed on clinical grounds alone, based on symptoms of painful urination, systemic symptoms (fever, malaise) and tender swollen prostate on exam. CBC and blood culture are often recommended to guide therapy. The most common cause is E. coli, however, a variety of pathogens may be responsible.
Treatment revolves around broad spectrum antibiotics. The drug therapy of choice is a quinolone (Ciprofloxacin). Trimethoprim-sulfamethoxazole is also an acceptable choice. In addition, general support measures such as analgesic & antipyretic (Acetaminophen), stool softner (Colace) and counseling should be provided.
ORDER
CBC with differential
Blood culture
Ciprofloxacin, oral, continuous
Acetaminophen, therapy, oral, continuous
Colace, oral, continuous
Reassure patient Counsel patient
Feedback5): Antibacterial therapy for acute bacterial prostatitis usually lasts 4 to 6 weeks. The patient should report improvement in symptoms within a few days. If the patient is septic (hypotensive), transfer to the hospital for intravenous antibiotics (gentamicin plus ampicillin). Follow-up with the patient can vary from a few days to a few weeks as there are no strict guidelines.
The patient is rescheduled for an appointment on Day 5 @ 10:00. This will advance the clock to Day 5 @ 10:00.
Feedback6): No additional end case orders are necessary in the time frame of this case.
Case 5: Complaint: Shortness of Breath Specialty: Medicine Topic: Pulmonology Setting: Ward
Case Summary
· 61-year-old hospitalized woman with shortness of breath.
· Vital signs show tachycardia (112 beats/min) and tachypnea (30/min).
· History reveals she was admitted 2 days ago for pneumonia. The shortness of breath began acutely and is associated with right sided chest pain that is worsened when taking a deep breath. She is on hormone replacement therapy.
· Examination shows loud S2 and right calf tenderness.
· Laboratory studies show elevated d-dimer, and spiral CT chest confirms pulmonary embolism.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: lung, heart, extremities · D-dimer · ECG · Spiral CT chest · PT/PTT · CXR· V/Q Scan · Exam: additional · Chest x-ray, portable · ABG· Cardiac enzymes · BNP - Brain natriuretic peptide · CBC · BMP - Basic metabolic profile
THERAPY · Oxygen · Heparin if stable· Thrombolytics if unstable · Intravenous access · Elevate head of bed · Nitroglycerin · Reassure patient · Coumadin
MONITORING · Pulse oximetry · Cardiac monitor · Vital signs · PT/PTT
LOCATION · Ward transfer to ICU
TIMING · Do not delay lungs and extremities exam.· For patients with high pretest probability of pulmonary embolism,spiral CT chest is recommended and quickest to diagnosis. Other options for diagnosis include ventilation-perfusion scan + d-dimer or pulmonary angiography.
SEQUENCING Orders Intravenous access, cardiac monitor, oxygen, pulse oximetry, elevate head of bed
Exam General, heart, lungs, extremities
Orders ECG 12 lead, ABG, chest x-ray portable, d-dimer, cardiac enzymes, BNP, CBC, BMP,nitroglycerin
Exam Skin, lymph nodes, HEENT, abdomen, rectal
Clock Advance to d-dimer result
Orders Spiral CT chest
Clock Advance to spiral CT result
Orders Heparin, PT/PTT, vital signs, reassure patient
Location Change to ICU
Clock Advance to case end
End Orders PT/PTT, coumadin
Feedback1): Initial vital signs show tachycardia and tachypnea. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor the heart rate and oxygenation.
ORDER REPORT TIME
Pulse oximetry Day 1 @ 19:05
Cardiac monitor Day 1 @ 19:05
Oxygen
Intravenous access
Elevate head of bed
Feedback2): Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. A lengthy examination should not be initially performed as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient.
Important aspects of the examination to note in this patient include:
General:
Degree of distress, cyanosis
Heart:
Elevated jugular venous pressure (Congestive heart failure)
S3 or S4 (Heart failure, Myocardial infarction)
Loud S2 (Sign of pulmonary hypertension)
Lungs:
Barrel chest, hyperressonance to percussion, vesicular breath sounds (COPD)
Coarse crackles (Bronchiectasis)
Rales (Congestive heart failure)
Pleural friction rub (may indicate pulmonary infarct)
Extremities:
Pain or tenderness (may be a sign of deep vein thrombosis)
Examination
General appearance
Chest/Lung
Heart/Cardiovascular
Extremities/Spine
Feedback3): In a hospitalized patient recovering from acute pneumonia, the following differential diagnoses should be considered in placing initial orders:· Pneumonia exacerbation - Chest X-ray· Pulmonary embolism o D-dimer - more useful to exclude PE if negative rather than include PE because it increases with many other disorders (e.g., metastatic cancer, trauma, sepsis, postoperative state).o ABG - may show decreased Pao2 & Paco2, increased pHo ECG - abnormal in 85% of patients with pulmonary embolismo Cardiac enzymes may show elevated troponin level because of right ventricular dilatationo Chest x-ray - often normal· Congestive heart failure - Chest x-ray, BNP (Brain natriuretic peptide)· Myocardial infarction - ECG, cardiac enzymes (Trial of nitroglycerin can also be diagnostically useful)· Anemia - CBC · COPD - Chest x-ray, ABG
ORDER REPORT TIME
ECG, 12 lead Day 1 @ 13:19
ABG - Arterial Blood Gas Day 1 @ 13:22
Chest X-ray, portable Day 1 @ 13:24
D-dimer, plasma Day 1 @ 13:34
Cardiac enzymes, serum Day 1 @ 14:04
BNP - Brain natriuretic peptide, serum Day 1 @ 14:04
CBC with differential Day 1 @ 13:34
BMP - Basic metabolic profile Day 1 @ 13:34
Nitroglycerin, sublingual, one time/bolus
Feedback4) Once initial orders have been placed, a more thorough examination can be performed to advance the clock while waiting for results.
Important aspects of the examination to note in this patient include:
Skin:
Diaphoresis (MI)
HEENT:
Fundoscopic exam - Papilledema (Hypertension)
Abdomen:
Hepatomegaly (CHF)
Rectal:
Bleeding may be a contraindication for potential blood thinning medications
Examination
Skin
Lymph nodes
HEENT/Neck
Abdomen
Rectal
Feedback5): For emergency cases, the clock should be advanced "with the next available result" as the results of individual tests may alter management.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 13:34.
Feedback6): The diagnosis of pulmonary embolism is based on a combination of clinical symptoms and diagnostic imaging. The gold standard is pulmonary angiography (3 hours), however the use of spiral CT (30 minutes) has become an excellent modality for diagnosing PE. Other imaging modalities include the ventilation-perfusion scan (2 hours) and doppler venous ultrasound of the lower extremities (2 hours). The following guidelines are generally accepted based on pretest probability. Criteria for determining pretest probability 1. PE more likely than alternatives: 3.0 points 2. Deep Vein Thrombosis (DVT) suspected: 3.0 points 3. Tachycardia (pulse >100 beats per minute): 1.5 points 4. Surgery or immobilization in last 4 weeks: 1.5 points 5. Prior DVT or Pulmonary Embolism: 1.5 points 6. Hemoptysis: 1.0 points 7. Active malignancy: 1.0 points Interpretation of pretest probability 1. Score 0-2 points: Low PE Probability (4% risk) 2. Score 3-6 points: Intermediate PE Probability (21% risk) 3. Score >6 points: High PE Probability (67% risk) · If high pretest probability - obtain spiral computed tomography of the chest. If positive, treat; If negative, obtain pulmonary angiography · If intermediate pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative, eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, treat. · If low pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative, eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, obtain pulmonary angiography. This patient would have a high pretest probability with a total of 9 points. Therefore, spiral CT is the best imaging modality choice for diagnosing pulmonary embolism.Positive D-dimer suggests PE more likely than alternative - 3 pointsPatient has calf tenderness with suspected DVT - 3 pointsTachycardia present - 1.5 pointsImmobilation from hospitalization for pneumonia - 1.5 points
ORDER REPORT TIME
Spiral computed tomography, chest Day 1 @ 14:04
Feedback7): The clock should be advanced to the results of the spiral CT. This can be done by advancing "With the next available result" or typing in the time to advance the clock to.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 14:04.
Feedback8): The management of pulmonary embolism involves: Anticoagulation - can order heparin with PT/PTT monitoring or enoxaparin (low molecular weight heparin) without PT/PTT monitoring. The use of thrombolytics (urokinase or streptokinase) is advised in massive PE with hemodynamic instability, however they are controversial in normotensive patients.In addiiton, vital signs should be monitored and reassurance provided.
ORDER REPORT TIME
PT/PTT Day 1 @ 14:34
Vital signs Day 1 @ 14:07
Heparin, therapy, intravenous, continuous
Reassure patient 5 minutes
Feedback9): Patients receiving treatment for pulmonary embolism require constant and close monitoring, therefore the patient should be transferred to the ICU.
The patient is transferred to the ICU.
Feedback10): The clock should be advanced "with the next available result" to advance to additional results and any patient updates.
The clock will be advanced to reveal each result in chronological order. This will advance the clock.
Feedback11): Heparin therapy requires PT/PTT monitoring which should be ordered in advance. In addition, treatment with coumadin is an integral component of long term therapy for pulmonary embolism and should be ordered in advance.
ORDER
PT/PTT
Coumadin, oral, continuous starting from Day 3
Case 6: Complaint: Back pain Specialty: Medicine Topic: Rheumatology Setting: Office
Case Summary
· 67-year-old woman with back pain for two days.
· Vital signs are unremarkable.
· History reveals sharp, constant, localized lower back pain. Acetaminophen only partly relieves the pain. Menopause at age 54.
· Examination shows mild kyphosis, tenderness at L4.
· Imaging reveals L4 - L5 vertebral compression fractures; DEXA scan shows osteoporosis with a T score of -2.8.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: spine/extremities, neuro · Spine x-ray, lumbosacral · DEXA scan · Exam: HEENT, lymph nodes +/- complete · CBC · BMP · Phosphorus · LFT · TSH
THERAPY · Back brace · Acetaminophen with oxycodone · Calcium carbonate · Vitamin D · Alendronate · Advise patient, exercise program · Colace · Advise patient, rest at home · Raloxifene · Diet, high calcium · Physical therapy · Advise patient, estrogen replacement therapy · Advise patient, side effects of medication · Reassure patient
MONITORING · Not important in the time frame of this case
LOCATION · Office
TIMING · Do not delay spine x-ray, Dexa scan, pain relief, and osteoporosis treatment.
SEQUENCING Exam HEENT, lymph nodes, spine/extremities, neuro +/- complete
Orders Spine x-ray lumbosacral
Clock Advance clock to spine x-ray
Orders CBC, BMP, phosphorous, LFT, TSH, DEXA scan, back brace, advise patient rest at home, acetaminophen plus oxycodone, colace
Clock Advance clock to reschedule patient when all results are reported
Orders Calcium carbonate, vitamin D, alendronate, raloxifene, diet of high calcium, physical therapy, advise exercise, advise estrogen replacement, advise side effects, reassure
Clock Advance to case end
End Orders None
Feedback1): In an office based case with a patient who is hemodynamically stable, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
HEENT:
Goiter, exopthalmos - Hyperthyroidism
Lymph nodes:
Enlarged - lymphoma
Extremities/Spine:
Localized tenderness - fracture (osteoporosis) or lytic lesions (multiple myeloma)
Neuro/Psych:
Muscle weakness - Vitamin D deficiency
Shooting pain with straight leg raise - Disc herniation
The following examinations will be performed. Examinations you requested will be used in assessing your score, but results will not be reported. Only results for the following examinations will be reported.
Examination
General appearance
Skin
Breasts
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Genitalia
Rectal
Extremities/Spine
Neuro/Psych
Feedback2): In a post-menopausal woman with back pain, it is important to rule out a vertebral fracture. A plain film x-ray should be reviewed at this visit to look for the presence of a fracture which will guide further management.
ORDER
Spine x-ray, lumbosacral
Feedback3): In a post-menopausal woman with a vertebral compression fracture, osteoporosis is likely the most common underlying cause. However, routine laboratory tests should be performed to exclude other causes and secondary osteoporosis:
· CBC (may be abnormal in multiple myeloma or malignancy that has spread to the bone marrow)
· BMP (Calcium low in hypoparathyroidism and renal disease; calcium high in hyperparathyroidism and malignancy)
· Phosphorus, serum (Low in hyperparathyroidism, malignancy, hyperthyroidism; normal in osteomalacia)
· LFT (Abnormal in liver disease, metastatic disease and alcoholism that may present as osteoporosis)
· TSH (Hyperthyroidism)
In addition, evaluation for osteoporosis and treatment for the fracture should be initiated:
· DEXA scan
· Back brace - to immobilize the spine so it can heal
· Rest
· Acetaminophen with oxycodone - for pain relief since acetaminophen by itself only partially worked
· Colace - for constipation caused by the oxycodone
ORDER
CBC with differential
BMP - Basic Metabolic Profile
Phosphorus, serum
LFT - Liver function panel
TSH, serum, ultrasensitive
DEXA scan
Back brace
Advise patient, rest at home Acetaminophen with oxycodone, oral, continuous Colace, oral, continuous
Feedback4): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 10:45).
The patient will be rescheduled for an appointment on Day3 @ 11:00. This will advance the clock to Day 3 @ 11:00.
Feedback5): The diagnosis of osteoporosis is based on a T score of - 2.5 or lower on DEXA scan. Treatment for osteoporosis may vary depending on various guidelines, but can include:· Calcium carbonate - for prevention and treatment of osteoporosis· Vitamin D - for prevention and treatment of osteoporosis· Alendronate - for prevention and treatment of osteoporosis· Raloxifene - reduces risk of vertebral fractue 40-50%· Advise patient on estrogen replacement therapy (Raloxifene is a selective estrogen receptor modulator)· Advise patient, side effects of medication· Lifestyle changes: diet with high calcium, advise on exercise program, physical therapy(Calcitriol and Calcitonin are additional options, but studies show they are less effective than alendronate for vertebral osteoporosis)
ORDER REPORT TIME
Calcium carbonate, oral, continuous
Vitamin D, therapy, oral, continuous
Alendronate, oral, continuous
Raloxifene, oral, continuous
Diet, high calcium
Physical therapy Day 4 @ 11:00
Advise patient, exercise program 5 minutes
Advise patient, estrogen replacement therapy 5 minutes
Advise patient, side effects of medication 5 minutes
Reassure patient 5 minutes
Counseling orders must be ordered and performed separately on the USMLE CCS cases, however in this case simulation you may place multiple counseling orders simultaneously. Counseling orders will advance the clock to Day 3 @ 11:20.
Feedback6): Follow-up for osteoporosis varies depending on treatement. Early in treatment, the patient may be reviewed every three months. Later, the patient may be reviewed annually for yearly DEXA scan.
The clock will be advanced to the next result.
Feedback7): No additional end case orders are necessary in the time frame of this case. Besides for follow-up of symptoms and performance status every 3 months, a repeat radiograph and DEXA scan in one year are generally recommended for follow-up.
Case 7: Complaint: Fatigue Specialty: Medicine Topic: Endocrinology Setting: Office
Case Summary
· 42-year-old woman with fatigue for four months.
· Vital signs show BMI of 39.6 kg/m2.
· History reveals two previous urinary tract infections.
· Laboratory examination reveals an elevated fasting blood glucose and hemoglobin A1c.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: HEENT, heart, rectal · BMP · Glucose, serum, fasting · Lipid profile · Hemoglobin A1c · Exam: complete · CBC · Urinalysis · Depression index · TSH · LFT · Magnesium · Urine microalbumin · ECG
THERAPY · Diet, low fat · Advise exercise program · Diet, diabetic · Diabetic teaching · Metformin · Aspirin · Lisinopril · Diet, calorie restricted · Consult, dietary · Consult, opthalmology · Consult, podiatry · Vaccine, influenza · Vaccine, pneumococcal · Advise side effects of medication · Advise medication compliance · Reassure
MONITORING · Hemoglobin AIc
LOCATION · Office · Admit if diabetic ketoacidosis or hyperosmolar nonketotic state present.
TIMING · Do not delay fasting glucose. · Order hemoglobin A1c after fasting glucose. · Do not delay diabetic education, diet and exercise recommendations.
SEQUENCING Exam HEENT, heart, abdomen, rectal, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, urinalysis, LFT, lipid profile, depression index, diet low fat, diet calorie restricted, advise exercise program
Clock Advance clock to reschedule patient when all results are reported
Orders Hemoglobin A1c, magnesium, urine microalbumin, ECG, consult opthalmology, consult dieatary, consult podiatry, diet diabetic, vaccine influenza, vaccine pneumococcal, diabetic teaching
Clock Advance clock to reschedule patient when all results are reported
Orders Metformin, aspirin, lisinopril, advise side effects, advise medication compliance, reassure
Clock Advance to case end
End Orders Hemoglobin A1c
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional. Important aspects of the physical exam in this patient include:HEENT: Enlarged thyroid - Thyroid abnormalityVision abnormalities - DiabetesPale conjunctiva - AnemiaHeart: Murmur - Hemolytic anemiaAbdomen:Abdominal mass - Renal cancerHepatomegaly - Liver diseaseRectal exam:Occult blood positive - Chronic blood loss, colon cancerLymph nodes:Enlarged - Metastatic cancer, lymphoma
Examination Time
General appearance 1 min
Skin 1 min
Breasts 1 min
Lymph nodes 1 min
HEENT/Neck 2 min
Chest/Lung 1 min
Heart/Cardiovascular 1 min
Abdomen 1 min
Rectal 2 min
Extremities/Spine 1 min
Neuro/Psych 1 min
Feedback2): Physical examination is non-specific, therefore important differential diagnoses to consider include: · Anemia (CBC) · Thyroid abnormalities (TSH) · Diabetes (fasting glucose) · Electrolyte abnormalities (BMP) · Renal disease (Urinalysis) · Liver disease (LFT) · Depression (Depression index) · Also, assessment of cardiac risk factors should be considered (Lipid profile). The patient is noted to be obese, therefore it is important to order lifestyle modifications with diet and exercise as outlined below.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
CBC with differential Day 1 @ 14:13
BMP - Basic Metabolic Profile Day 1 @ 12:43
Urinalysis Day 1 @ 16:13
LFT Day 1 @ 12:43
Glucose, serum, fasting Day 1 @ 11:13
TSH, serum, ultrasensitive Day 3 @ 10:13
Lipid profile Day 3 @ 10:13
Depression index Day 1 @ 10:23
Diet, low fat
Diet calorie-restricted
Advise patient, exercise program 5 minutes
Counseling orders will advance the clock to Day 1 @ 10:18.
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 10:13).
Feedback4): The diagnosis of diabetes mellitus is based on the following criteria:· Random plasma glucose of 200mg/dL (11.1mmol/L) or higher, plus symptoms of diabetes · Fasting plasma glucose of 126mg/dL (7.0mmol/L) or higher · Plasma glucos
1) Feedback: The patient is hemodynamically unstable with initial vital signs showing tachycardia, tachypnea and hypotension. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor blood pressure, heart rate and oxygenation.
Beck's triad
a)Decrease in systemic arterial pressure
b)Elevated central venous pressure
c)Small, quiet heart
ORDER
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Oxygen
Intravenous access
Normal saline, 0.9% NaCl
Elevate foot of bed
2)Feedback: Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. A lengthy examination should not be initially performed in a hemodynamically unstable patient as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient.
Important aspects of the examination to focus on in this patient include:
General:
Responsiveness, amount of distress, stupor
Heart:
Soft heart sounds, distended neck veins, pulsus paradoxus (Cardiac tamponade)
Harsh systolic murmur, upper extremity hypertension, diminshed femoral pulses (Aortic injury)
Lungs:
Reduced breath sounds, hyperresonance to percussion (Tension pneumothorax)
Reduced breath sounds, dullness to percussion (Hemothorax)
Reduced breath sounds, moist rales, chest wall bruising (Pulmonary contusion)
3) Feedback: The physical examination reveals soft heart sounds, weak pulse, jugular venous distension and pulsus paradoxus. These findings strongly point to the diagnosis of cardiac tamponade.
Treatment for cardiac tamponade should be instituted based on the physical examination and should not be delayed for results of any laboratory or imaging studies. Therefore, it is imperative to order pericardiocentesis at this point. A surgery consult is automatically ordered when you order pericardiocentesis. A reason for consultation is requested on the USMLE CCS cases, but is not graded; therefore it is not requested in these case simulations. A reasonable entry might include "patient with signs of cardiac tamponade requiring urgent pericardiocentesis".
Additional studies to help confirm the diagnosis and rule out other diagnoses should also be ordered as shown below.
· Echocardiography - gold standard for diagnosis of cardiac tamponade.
· Chest x-ray - may show enlarged cardiac silhouette
· ECG - may show low-voltage QRS complexes, ST segment elevation, or PR segment depression. Electrical alternans is pathognomonic of cardiac tamponade and is characterized by alternating levels of ECG voltage of the P wave, QRS complex, and T waves.
Pain management is also a consideration but not weighted heavily in the time frame of this case.
Additional orders (ESR, thyroid function tests, ANA, Rheumatoid Factor, PPD, blood cultures, viral titers, and pericardial fluid analysis and cultures) are often ordered when the cause of pericardial tamponade is not known. However, in this case, acute pericardial tamponade is directly related to trauma therefore these additional studies are not necessary.
ORDER
Pericardiocentesis
Consult, surgery, thoracic
ECG, 12 lead
Chest X-ray, portable
Echocardiography
Morphine, intravenous, one time/bolus
4) Feedback: Once initial diagnosis and treatment has been instituted, a more thorough physical examination can be performed to look for additional injuries and guide further management.
Examination
Skin
HEENT/Neck
Abdomen
Genitalia
Rectal
Extremities/Spine
Neuro/Psych
5) Feedback: The following routine trauma orders following a motor vehicle accident are not necessarily directly related to the management of cardiac tamponade and therefore are not weighted heavily in scoring. They may earn a small amount of points and are therefore included in the management of this case.
· Routine orders for monitoring bleeding and detecting electrolyte imbalances - CBC, BMP, PT/PTT, type and crossmatch blood
· Blunt chest/abdominal trauma orders - Cardiac enzymes (damage to the heart), amylase (damage to the pancreas)
· Routine X-rays following MVA: Chest x-ray (previously ordered), pelvis x-ray and cervical spine x-rays.
· Routine toxicology screening in MVA: Blood alcohol and toxicology screen
ORDER
CBC with differential
BMP - Basic Metabolic Profile
PT/PTT
Cardiac enzymes, serum
Amylase, serum
Cervical spine films, portable
Pelvic x-ray, portable
Alcohol, blood
Toxicology screen, urine
Type and crossmatch, blood
6) Feedback: Once all relevant examinations have been performed and orders have been placed, the clock can be advanced to obtain results. For emergency cases, the clock should be advanced "with the next available result" as management may change with individual results.
7) Feedback: Following pericardiocentesis, it is important to confirm relief of the cardiac tamponade with a repeat chest x-ray and echocardiography. In addition, vital signs must be monitored regularly to ensure improvement following treatment.
ORDER
Chest X-ray, portable
Echocardiography
Vital signs
8) Feedback: After placing monitoring orders following pericardiocentesis, the clock can be advanced "with the next available result" to reveal results of the vital signs and check for patient updates.9)Feedback: Following pericardiocentesis, the patient should be monitored in the ICU. However, transferring the patient may be beyond the time frame of this case, therefore it is not weighted heavily in scoring.
The patient is transferred to the ICU. 10) Feedback: The clock can be advanced "with the next available result" to reveal additional results and check for patient updates. 11) Feedback: Although not heavily weighted, since the patient was not wearing a selt belt, it is advisable to counsel him to wear a selt belt once he has recovered. SEQUENCING Orders Blood pressure monitor, cardiac monitor, oxygen, pulse oximetry, elevate foot of bed, intravenous access, normal saline 0.9% NaCl
Exam General, heart, lungs
Orders Pericardiocentesis, consult thoracic surgery, chest x-ray, ECG, echocardiography, morphine
Exam Additional: skin, HEENT, abdomen, extremities + others
Orders CBC, BMP, PT/PTT, cardiac enzymes, amylase, type & crossmatch blood, alcohol blood, cervical spine x-rays, pelvis x-ray, toxicology urine
Clock Advance to pericardiocentesis
Orders Chest x-ray, echocardiography, vital signs
Clock Advance to vital signs
Location Transfer to ICU
Clock Advance to additional results and case end
End Orders Advise patient drive with seat belt
Case 23: Complaint: Fatigue Specialty: Medicine Topic: Hematology Setting: Office
Case Summary
· 58-year-old man with fatigue and weakness for 3 months.
· Vital signs are unremarkable.
· History reveals tongue pain, mild confusion, memory loss, poor diet, smoker of 1 pack per day for 35 years, heavy alcohol use.
· Examination shows pale conjunctiva, tongue enlarged and reddened, mild hepatosplenomegaly, mildly diminshed deep tendon reflexes.
· Laboratory studies show abnormal LFT (elevated AST/ALT with AST 3 times greater than ALT, low albumin), CBC with macrocytic anemia and hypersegmented neutrophils, low vitamin B12, low folic acid.
· Abdominal ultrasound reveals fatty liver.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: HEENT, neuro · CBC · LFT · Vitamin B12, serum · Folic acid, serum · Folic acid, erythrocyte · · Exam: complete · BMP · TSH · Glucose, fasting · Reticulocyte count · Ferritin · Iron & TIBC · PT/PTT · Hep B surface antigen · Hep C antibody · Abdominal ultrasound
THERAPY · Advise, no smoking · Advise, no alcohol · Alcoholics Anonymous · Vitamin B12, therapy · Folic acid, therapy · Thiamine · Consult, dietary · Reassure · Counsel
MONITORING · CBC
LOCATION · Office
TIMING · Do not delay CBC. · Order CBC first, then follow with vitamin B12 and folic acid levels. · Do not delay counseling to stop smoking, stop alcohol use, and improve nutrition.
SEQUENCING Exam Complete
Orders CBC, BMP, LFT, TSH, glucose fasting, advise no smoking, advise no alcohol, Alcoholics Anonymous
Clock Advance clock to reschedule patient when all results are reported
Orders Reticulocyte count, vitamin B12 serum, folic acid serum, folic acid eryhtrocyte, ferritin, iron & TIBC, PT/PTT, hep B surface antigen, hep C antibody, abdominal ultrasound
Clock Advance clock to reschedule patient when all results are reported
Orders Vitamin B12 therapy, folic acid therpy, thiamine, consult dietary, reassure, counsel
Clock Advance to case end
End Orders CBC
Feedback1): In an office based case with a patient who is hemodynamically stable, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
Skin:
Jaundice - Liver disease
HEENT:
Mucosal and conjunctival pallor - Anemia
Glossitis - Folate or vitamin B12 deficiency
Goiter - Thyroid abnormalities
Vision abnormalities - Diabetes
Lymph nodes:
Enlarged lymph nodes - Lymphoma, metastatic disease
Abdomen:
Hepatomegaly - Liver disease
Abdominal mass - Cancer
Rectal:
Occult blood positive - Chronic blood loss, Colon cancer
Hard, irregular prostate - Prostate cancer
Neuro/Psych:
Gait disturbance, loss of reflexes and mental status changes - Vitamin B12 deficiency
Feedback2): On physical examination, the patient has signs of anemia. A CBC should be ordered first in the work-up of anemia.:
In addition, it is important to rule out other differential diagnoses of fatigue, such as thyroid abnormalities (TSH), diabetes (fasting glucose), electrolyte abnormalities (BMP), and liver disease from alcohol use (LFT).
The patient is noted to smoke and drink alcohol in the initial history and it is imperative to advise him to stop smoking and drinking alcohol (Alcoholics anonymous, advise patient no alcohol and advise patient no smoking)
ORDER
CBC with differential
BMP - Basic Metabolic Profile
LFT - Liver function profile
Glucose, serum, fasting
TSH, serum, ultrasensitive
Alcoholics anonymous
Advise patient, no alcohol 5 minutes Advise patient, no smoking 5 minutes
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 11:00). Since appointments can only be scheduled Mon-Fri 9-5 in the office setting, the next available appointment is Day 4 @ 09:00 (Mon).
The patient will be rescheduled for an appointment on Day 4 @ 09:00. This will advance the clock to Day 4 @ 09:00.
Feedback4): CBC reveals megaloblastic anemia. Additional work-up should include:
· Vitamin B12, serum - low level indicates Vitamin B12 deficiency; keep in mind false positive may be seen in malabsorption syndrome and hypothyroidism
· Folic acid, serum - only indicates negative folate balance, therefore also need RBC folate to determine true deficiency
· Folic acid, erythrocyte (RBC Folate) - Low when body stores are depleted. Alone not reliable, but must be correlated with serum B12 and folate.
· Reticulocyte count - indicates level of RBC production and may be the first indication of successful treatment
· Ferritin & Iron studies - Up to 1/3 of patients with Vitamin B12 and Folate deficiency also have Iron deficiency.
In addition, liver function tests show aspartate (AST) two to three times higher than the alanine aminotransferase (ALT) and low albumin consistent with alcoholic hepatitis. Serum glucose is often low in the alcoholic patient secondary to the attendant malnutrition and cirrhosis and inhibition by alcohol of gluconeogenesis. Additional work-up of alcoholic hepatitis should be ordered:
· Hepatitis B & C serology - essential in assessment to rule out contributing viral hepatitis.
· PT/PTT - test of hepatic synthetic function and can be used to assess severity
· Abdominal ultrasound - can detect fatty infiltration and may detect cirrhosis
ORDER
Reticulocyte count, blood
Vitamin B12, serum
Folic acid, serum
Folic acid, erythrocyte
Ferritin, serum
Iron and total iron binding capacity, serum
PT/PTT
Hepatitis B surface antigen, serum
Hepatitis C antibody, serum
Abdominal ultrasound
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after Day 7 @ 9:00).
Feedback6): Treatment for Vitamin B12 and folate deficiency should include replacement of each and also address possible thiamine deficiency. In addition, general counseling and nutrition replacement (dietary consult) should accompany alcohol abstinence (previously ordered) for treatment of alcoholic hepatitis.
ORDER
Vitamin B12, therapy, oral continuous
Folic acid, therapy, oral continuous
Thiamine, oral, continuousConsult, dietary Day 8 @ 10:00 Reassure patient 5 minutes Counsel patient 5 minutes
Feedback7): The patient should be rescheduled in 1-2 weeks for a check of improvement in CBC and symptoms.
Feedback8): Weekly CBC should be monitored for improvement, however it may not be necessary in the time frame of this case.
ORDER
CBC
Case 28: Complaint: Fatigue and Irritability Specialty: Pediatrics Topic: Hematology Setting: Office
Case Summary
· 27-month-old boy with fatigue and irritability for 2 months. · Vital signs are unremarkable. · History reveals child is a fussy eater, drinking mainly milk and juices and refusing to eat meat and vegetables. · Physical examination reveals pallor. · Laboratory studies show CBC with microcytic anemia and basophilic stippling of erythrocytes, decreased ferritin & serum iron, and blood lead level of 52 mcg/dL.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: skin · CBC · Ferritin · Lead, blood quantitative · Exam: additional · Reticulocyte count · Iron and total iron-binding capacity
THERAPY · Iron sulfate · Lead chelation - succimer · Consult, dietary · Lead abatement agency · Diet, high iron · Iron-enriched infant formula · Advise, limit intake of cow's milk · Reassure · Counsel patient/family
MONITORING · CBC · Lead, blood quantitative · Ferritin
LOCATION · Office
TIMING · Do not delay CBC. · Order CBC first, then ferritin and lead levels.
SEQUENCING Exam Complete
Orders CBC
Clock Advance clock to results of CBC
Orders Ferritin, iron & TIBC, lead blood, reticulocyte count
Clock Advance clock to reschedule patient when all results are reported
Orders Iron sulfate, lead chelation - succimer, iron-enriched infant formula, lead abatement agency, diet high iron, advise limit intake of cow's milk, reassure, consult dietary, counsel
Clock Reschedule patient depending on elevated lead levels (2 days if >50)
Orders Lead blood
Clock Avance clock to any additional updates.
End Orders CBC, lead, ferritin
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
Skin:
Pallor - Anemia
HEENT:
Pale conjunctiva - Anemia
Glossitis, angular stomatitis - Vitamin deficiency, anemia
Heart:
Murmur - Hemolytic anemia
Rectal exam:
Occult blood positive - Chronic blood loss
The following examinations will be performed. Examinations you requested will be used in assessing your score, but results will not be reported. Only results for the following examinations will be reported.
Examination
Time
General appearance
Skin
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Rectal
Extremities/Spine
This will advance the clock to: Day 1 @ 11:11
Feedback2): The work-up of pallor in an infant should begin with a complete blood count. This will confirm the presence of anemia and can provide clues to the cause. Once anemia is confirmed, then a work-up of the cause of anemia should be performed.
Feedback3): The clock should be advanced "with the next available result" to advance to the CBC results.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 10:11.
Feedback4): The differential causes of microcytic anemia include: Ferritin Iron, serum TIBC RBC RDW Lead, blood FEP
Chronic disease N to H L L N, L, H N to H N N, H
Lead poisoning N N N N N, H H H
Iron deficiency L L H L H N N, H
Sideroblastic H H L N H N N
Thallasemia N to H N N H N N N
L = Low N = Normal H = HighLaboratory studies that can be useful to help differentiate the cause of microcytic anemia include:· CBC - Low Hemoglobin, Low MCV confirms microcytic anemia. o Hypochromasia, poikilocytes seen in Iron deficiency. o Basophilic stippling seen in lead poisoning. o RDW increased in Iron deficiency, normal in thallasemia. o RBC high in thallasemia, low in iron deficiency · Ferritin, serum - Decreased level most useful for diagnosing iron deficiency · Serum Iron & TIBC - Additional studies to confirm iron deficiency · Blood lead, quantitative - Used as screening for lead poisoning · Free erythrocyte protoporphyrin (FEP) - May be increased in lead poisoning, iron deficiency and chronic disease, not specific. · Hemoglobin electrophoresis - should be ordered only if other tests are negative. o High Hemoglobin A2 in Beta-thallasemia. o Alpha-thallasemia is a diagnosis of exclusion when hypochromic microcytic anemia seen in familial form with normal iron studies, lead studies, and hemoglobin electrophoresis.
ORDER REPORT TIME
Ferritin, serum Day 2 @ 10:11
Iron and total iron binding capacity, serum Day 2 @ 10:11
Lead, blood, quantitative Day 2 @ 10:11
Reticulocyte count, blood Day 2 @ 10:11
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after Day 2 @ 10:11). Although some treatment orders can be started, it is best to obtain a proper diagnosis of the anemia prior to initiating treatment. The patient will be rescheduled for an appointment on Day 2 @ 11:00. This will advance the clock to Day 2 @ 11:00.
Feedback6): Results show iron deficiency anemia and lead poisoning. Treatment of iron deficiency anemia includes:· Oral medications - Iron sulfate. Multivitamins with iron are inadequate for treatment. · Diet modifications to increase iron intake - Diet high iron, Iron enriched infant formula, Avoid cow's milk and consult dietary · Monitoring of improvement - Symptoms improve in 3-4 days, CBC in 1 month, Ferritin in 3 months Treatment of Lead poisoning depends on the blood lead levels: BLL Action <10 No action needed10-19 Repeat blood test within 3 months, Counsel20-44 Repeat blood test within 1 month, Counsel, refer to lead abatement agency (LAA)45-69 Repeat blood test within 1-2 days, Counsel, referral LAA, oral chelation therapy (succimer)>70 Hospitalization, stat venous blood test, education, referral LAA, IV chelation therapy (EDTA)
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Lead chelation - succimer
Iron sulfate, oral, continuous
Iron-enriched infant formula
Diet, high iron
Lead abatement agency
Consult, dietary Day 3 @ 11:00
Counsel patient/family 5 minutes
Advise patient, limit cow's milk intake 5 minutes
Reassure patient 5 minutes
Counseling orders must be ordered and performed separately on the USMLE CCS cases, however in this case simulation you may place multiple counseling orders simultaneously. Counseling orders will advance the clock to Day 2 @ 11:15.
Feedback7): For lead levels greater than 50, the patient should be rescheduled in 1-2 days for repeat blood lead level.
Feedback8): For initial lead levels greater then 50, repeat blood levels should be measured in 1-2 days to ensure improvement with therapy.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Lead, blood, quantitative Day 5 @ 09:00
Feedback9): At this point, the patient can be rescheduled in about 1-4 weeks for repeat CBC and lead levels.
The patient will be rescheduled for Day 30 @ 09:00. This will advance the clock.
Feedback9): Normal response to treatment for iron deficiency anemia:
1-2 days: Improvement in symptoms such as appetite and irritability
4-30 days: Improvement in hemoglobin levels (CBC should return to normal by 1 month)
1-3 months: Repletion of iron stores (Ferritin should return to normal by 3 months).
Continue oral iron therapy for 8 weeks after hemoglobin level returns to normal.
ORDER ORDER TIME
CBC with differential 1 week
Ferritin, serum 2 months
Lead, blood, quantitative 1 month
Case 1: Complaint: Motor vehicle accident
Specialty: Surgery Topic: Trauma Setting: Emergency Department
Case Summary
· 33-year-old man with chest pain and respiratory distress following a motor vehicle accident.
· Vital signs show tachycardia (118 beats/min), tachypnea (32 breaths/min), and hypotension (100/60 mm Hg).
· History reveals he was the unrestrained driver and his chest hit the steering wheel. He did not hit his head and there was no loss of consciousness. He was initially alert and responsive and then became dyspneic, agitated, and restless in the ambulance prior to arrival in the emergency department.
· Examination reveals soft heart sounds, weak central and peripheral pulse, jugular venous distension, and pulsus paradoxus.
· ECG reveals electrical alternans; chest x-ray shows enlarged cardiac silhouette; echocardiography reveals cardiac tamponade.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: general, lungs, heart· Chest x-ray, portable· Echocardiography· ECG, 12 lead · Exam: additional · CBC · BMP · PT/PTT · Cardiac enzymes · Amylase · Cervical spine x-ray · Pelvis x-ray · Alcohol, blood · Toxicology screen, urine
THERAPY · Pericardiocentesis (Consult thoracic surgery automatically ordered)· Oxygen · Intravenous access · Normal saline, 0.9% NaCl · Elevate foot of bed · Morphine, intravenous, one-time/bolus · Type and crossmatch, blood · Advise patient, drive with seat belt
MONITORING · Blood pressure monitor, continuous · Cardiac monitor · Pulse oximetry · Echocardiography · Chest x-ray, portable · Vital signs
LOCATION · Emergency department; transfer to ICU for monitoring after pericardiocentesis.
TIMING · Monitoring orders do not take time off the clock and should be ordered prior to any physical exam. · Do not delay cardiac exam. · Order for pericardiocentesis should be made on results of the cardiac exam and should not be delayed for results of chest x-ray or echocardiogram.
SEQUENCING Orders Blood pressure monitor, cardiac monitor, oxygen, pulse oximetry, elevate foot of bed, intravenous access, normal saline 0.9% NaCl
Exam General, heart, lungs
Orders Pericardiocentesis, consult thoracic surgery, chest x-ray, ECG, echocardiography, morphine
Exam Additional: skin, HEENT, abdomen, extremities + others
Orders CBC, BMP, PT/PTT, cardiac enzymes, amylase, type & crossmatch blood, alcohol blood, cervical spine x-rays, pelvis x-ray, toxicology urine
Clock Advance to pericardiocentesis
Orders Chest x-ray, echocardiography, vital signs
Clock Advance to vital signs
Location Transfer to ICU
Clock Advance to additional results and case end
End Orders Advise patient drive with seat belt
Case 2: Complaint: Fatigue
Specialty: Surgery Topic: Gastroenterology Setting: Office
Case Summary
· 66-year-old man with fatigue and constipation for 4 months.
· Vital signs are unremarkable.
· History reveals occasional left lower quadrant abdominal pain, 9-kg (20-lb) weight loss, smoking 1 pack cigarettes a day for 30 years.
· Examination shows occult blood positive.
· CBC reveals microcytic anemia; colonoscopy reveals colon adenocarcinoma.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: rectal, HEENT, lymph nodes· CBC · Ferritin · CEA · Colonoscopy · Exam: additional +/- complete· BMP · TSH · Glucose fasting · LFT · Urinalysis · Iron and TIBC · Abdominal CAT scan · Chest CT · Bone scan · ECG · PT/PTT
THERAPY · Advise, no smoking · Advise, cancer diagnosis · Colectomy · Consult, general surgery · Iron sulfate · Reassure · Type and crossmatch, blood
MONITORING · CBC · CEA · Ferritin
LOCATION · Office
TIMING · Do not delay rectal exam or colonoscopy. · Order CBC first, then iron studies, then iron sulfate.
SEQUENCING Exam Rectal, HEENT, heart, abdomen, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, LFT, urinalysis, colonoscopy, advise no smoking
Clock Advance clock to reschedule patient when all results are reported
Orders Ferritin, iron & TIBC, CEA, abdominal CAT scan, chest CT scan, bone scan, advise cancer diagnosis, reassure
Clock Advance clock to reschedule patient when all results are reported
Orders Colectomy, consult general surgery, iron sulfate, ECG, PT/PTT, type and crossmatch blood
Clock Advance to case end
End Orders CBC, CEA, ferritin
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
HEENT:
Enlarged thyroid - Thyroid dysfunction
Vision abnormalities - Diabetes
Pale conjunctiva - Anemia
Heart:
Murmur - Hemolytic anemia
Abdomen:
Abdominal mass - Renal cancer
Rectal exam:
Occult blood positive - Chronic blood loss, colon cancer
Hard, irregular prostate - Prostate cancer
Lymph nodes:
Enlarged - Metastatic cancer, lymphoma
Examination
General appearance
Skin
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Rectal
Extremities/Spine
Neuro/Psych
Feedback2): On physical examination, the patient is fecal occult blood positive. Colonoscopy is the general standard for work-up of fecal occult blood positive stools. If colonoscopy is negative, EGD can be considered or both may be ordered simulataneously.
In addition to colonoscopy, it is important to rule out other differential diagnoses, such as
· Anemia (CBC)
· Thyroid abnormalities (TSH)
· Diabetes (fasting glucose)
· Electrolyte abnormalities (BMP)
· Renal disease (Urinalysis)
· Liver disease (LFT)
The patient is noted to smoke in the initial history and it is imperative to advise all patients to stop smoking.
ORDER
CBC with differential
BMP - Basic Metabolic Profile
Urinalysis
LFT - Liver function profile
Glucose, serum, fasting
TSH, serum, ultrasensitive
Colonoscopy
Advise patient, no smoking
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 11:15).
Feedback4): Results show the patient has a colon adenocarcinoma and microcytic anemia. Important tests to consider at this point include:· Ferritin, Iron & TIBC - To confirm the microcytic anemia is sceondary to iron loss from chronic blood loss. · CEA - levels can be useful for prognosis and monitoring postoperative course in colon cancer. · Abdominal CAT scan, Chest CT (or chest x-ray), Bone scan - Evaluation for metastatic disease · Appropriate counseling orders Referral to a specialist is more appropriate once clinical staging of the tumor is better known. Surgery is generally the treatment of choice, however adjuvant therapy may be used and stage IV disease is usually treated with chemotherapy.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
Ferritin, serum Day 4 @ 11:00
Iron and total iron binding capacity, serum Day 4 @ 11:00
CEA, serum Day 5 @ 11:00
Abdominal CAT scan Day 4 @ 11:00
Chest CT scan Day 4 @ 11:00
Bone scan Day 4 @ 11:00
Advise patient, cancer diagnosis 5 minutes
Reassure patient 5 minutes
Feedback5): The patient should be rescheduled for an appointment once all results have been reported (after day 5 @ 11:00). Since office hours are Mon-Fri 9-5, the next available appointment is Day 7 @ 9:00.
Feedback6): The first-line curative treatment for colorectal carcinoma is surgery. Adjuvant chemo/radiation therapy is often used for higher stage tumors once pathologic staging is determined following resection. Routine pre-operative orders (ECG, PT/PTT, Type and crossmatch) may generate a small amount of points. In addition, treatment of iron deficiency anemia with iron sulfate should be started.
ORDER REPORT TIME
Colectomy, by laparotomy Day 8 @ 9:00
ECG, 12 lead Day 7 @ 11:00
PT/PTT Day 7 @ 9:30
Type and crossmatch, blood Day 7 @ 15:00
Consult, general surgery Day 7 @ 10:00
Iron sulfate, oral, continuous
Feedback7): The clock should be advanced to the colectomy procedure.
Feedback8): Important orders to monitor in this patient, which may generate a small amount of points include:
· CBC - should return to normal within 1 month.
· Ferritin - should return to normal within 3 months.
· CEA - levels usually return to normal by 6 weeks following resection.
Case 3: Complaint: Abdominal pain Specialty: Obstetrics & Gynecology Topic: Obstetrics Setting: Emergency Department
Case Summary
· 19-year-old woman with abdominal pain for 6 hours.
· Vital signs show tachycardia (106 beats/min), hypotension (100/60 mm Hg), low-grade fever (38.2°C, 100.8°F).
· History shows pain is sharp, constant, and focused predominately in the right lower quadrant. History is also significant for 6 weeks amenorrhea, vaginal spotting, sexual activity with three men, occasional use of condoms, and previous treatment for Chlamydia.
· Examination reveals lower abdominal tenderness, closed cervical os, cervical excitation present and right adnexal mass with tenderness.
· Laboratory studies reveal positive urine HCG test.
· Imaging with transvaginal ultrasound shows a complex right adnexal cyst.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: genitals, abdomen · HCG, beta, urine, qualitative · Transvaginal ultrasound · Exam: lungs, heart · CBC · BMP · PT/PTT · HCG, beta, serum, quantitative
THERAPY · Laparotomy · Normal saline, 0.9% NaCl · Intravenous access · Oxygen · Consult, obstetrics & gynecology · Elevate foot of bed · Morphine, intravenous, one-time/bolus · RhoGAM · Type and crossmatch, blood · Advise patient, safe sex techniques
MONITORING · Blood pressure monitor, continuous · Cardiac monitor · Pulse oximetry · CBC
LOCATION · Emergency department · Patient should be taken directly to surgery.
TIMING · Emergency monitoring orders do not take time off the clock and should be ordered prior to any physical exam. · Do not delay abdominal and genital exam. · Urine HCG test should be ordered immediately following exam. · Order for laparotomy should be made immediately after HCG result as patient is hemodynamically unstable. It should not be delayed for results of transvaginal ultrasound.
SEQUENCING Orders Blood pressure monitor, cardiac monitor, pulse oximetry, oxygen, intravenous access, normal saline, elevate foot of bed
Exam Abdomen, genitalia + general, heart, lungs
Orders HCG urine, morphine
Clock Advance to HCG results
Orders Laparotomy, consult OB/GYN, transvaginal ultrasound, type & crossmatch blood, HCG serum quantitative, CBC, BMP, PT/PTT
Clock Advance to laparotomy and case end
End Orders CBC, RhoGAM; advise patient safe sex techniques
Feedback1): The patient is hemodynamically unstable with initial vital signs showing tachycardia and hypotension. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor blood pressure, heart rate and oxygenation.
ORDER
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Oxygen
Intravenous access
Normal saline, 0.9% NaCl, Intravenous
Elevate foot of bed
Feedback2): Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. In addition, examination of the abdomen and genitalia are critical in a young woman with abdominal pain. A complete physical examination should not be initially performed as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient. Important aspects of the examination to note in this patient include:General: Distress and pallor may indicate blood lossHeart: Tachycardia and hypotension - Shock due to ruptured ectopicAbdomen: Periumbilical or right lower quadrant tenderness - Acute appendicitis.Fetal heart auscultationGenitalia: Large amount of blood loss and open cervical os - Spontaneous abortionAdnexal tenderness and cervical excitation - Ectopic pregnancyVaginal dischage, tender adnexal mass, cervical excitation - Pelvic inflammatory disease
Examination Time
General appearance 1 min
Chest/Lung 1 min
Heart/Cardiovascular 1 min
Abdomen 1 min
Genitalia 2 min
Feedback3): In a young woman with acute abdominal pain, amenorrhea for 6 weeks and intermittent vaginal bleeding, a pregnancy test is a crucial to initially differentiate between various differential diagnoses.
Pregnancy-related: Ectopic pregnancy, spontaneous abortion
Non-pregnancy related: Pelvic inflammatory disease, endometriosis, dysfunctional uterine bleeding, or acute appendicitis.
In addition, pain relief should be considered early, however in the time frame of this case, analgesia is not weighted heavily in scoring.
ORDER
HCG, beta, urine, qualitative
Morphine, intravenous, one time/bolus
Feedback4): For emergency cases, the clock should be advanced "with the next available result" as the result of the HCG test is critical in further management. Alternatively, you may chose to advance the clock 5 minutes by performing additional physical examinations instead of using the obtain results button (not shown here).
Feedback5): In a hemodynamically unstable patient with a positive pregnancy test and signs of ectopic pregnancy, laparotomy should be immediately ordered without waiting for results of a transvaginal ultrasound. Laparoscopy is a reasonable alternative and is considered safer, but will require a longer wait time. If the patient was hemodynamically stable, a transvaginal ultrasound may help differentiate between ectopic pregnancy and spontaneous abortion to help guide further management.
In addition to laparotomy, additional orders to consider include:
Transvaginal ultrasound - to evaluate adnexal mass and presence of intrauterine pregnancy
Obstetrics/gynecology consultation
CBC - leukocytosis may be seen in ectopic pregnancy, low hemoglobin in blood loss
BMP, PT/PTT and type & crossmatch blood - Routine pre-op orders
Serum HCG - Serial measurements after surgery to ensure complete removal.
ORDER
Laparotomy Consult, obstetrics/gynecology
Transvaginal ultrasound
Type and crossmatch, blood
HCG, beta, serum, quantitative
CBC with differential
BMP - Basic Metabolic Profile
Feedback6): Once all relevant orders are placed, the clock can be advanced to obtain results. For emergency cases, the clock should be advanced "with the next available result" as management may change with individual results. Alternatively, it is also acceptable to initially advance the clock by performing additional physical examinations, not shown in this management strategy.
Feedback7): Although end case orders may not be necessary in the time frame of this case, the following additional orders should be considered as important in the management of ectopic pregnancy and may generate some additional points.
CBC should be monitored to determine the need for transfusion.
Rhogam is normally administered to Rh negative patients within 48 hours to prevent sensitization.
The patient should be counseled about safe sex techniques once recovered.
ORDER
CBC with differential Rhogam, intramuscular, one time/bolus Advise patient, safe sex techniques
Case 4: Complaint: Back pain Specialty: Medicine Topic: Nephrology Setting: Office
Case Summary
· 28-year-old man with painful urination and low back pain.
· Vital signs show elevated temperature (38.0°C, 100.4°F).
· History reveals sharp and severe pain during urination, increased urinary frequency, nocturia, chills, and perineal pain.
· Examination shows tender swollen prostate.
· Laboratory studies show urinalysis positive for blood, nitrite, leukocyte esterase, leukocytes, and bacteria. Urine Gram stain positive for gram-negative rods. Urine culture positive for Escherichia coli. CBC with elevated WBC count.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: rectal · Urinalysis · Urine Gram stain · Urine culture · Exam: general, lungs, heart, genitalia · CBC · Blood culture
THERAPY · Ciprofloxacin/TMP-SMZ· Acetaminophen · Colace · Reassure · Counsel patient/family
MONITORING · Not important for this case
LOCATION · Office
TIMING · Do not delay prostate exam or ciprofloxacin. · Examine results of urine studies at the initial visit.
SEQUENCING Exam General, abdomen, genitalia, rectal +/- complete
Orders Urinalysis, urine Gram stain, urine culture
Clock Advance clock to results of urinalysis and Gram stain
Orders CBC, Blood culture, ciprofloxacin, acetaminophen, colace, reassure, counsel
Clock Advance clock to additional results and patient update
End Orders None
Feedback1): In the office setting with a patient not in acute distress, it is appropriate to begin management with the physical examination. Although a complete physical exam would be optional since the patient is hemodynamically stable, it is more appropriate to narrow and focus the physical examination.
Important aspects of the physical exam include:
Genitalia:
Urethral discharge for culture
Rectal:
Tender, swollen prostate - prostatitis
Hard & irregular prostate - cancer
Fluctuant prostate - prostatic abscess
Examination
General appearance
Skin
Lymph nodes
Chest/Lung
Heart/Cardiovascular
Abdomen
Genitalia
Rectal
Feedback2): Important orders to consider in this patient include: Urinalysis:Leukocyte esterase - Increased (UTI, Gonorrhea or Chlamydia, Prostatitis), Normal (Renal calculi)Blood - Increased (Renal calculi, UTI)White blood cells - same as leukocyte esteraseBacteria - Increased (UTI, Prostatitis), Normal (Gonorrhea or chlamydia, Renal calculi)Urine culture
ositive (UTI, Prostatitis), Negative (Gonorrhea & Chlamydia, Renal calculi) Note: DO NOT ORDER PROSTATIC MASSAGE as prostatic massage may lead to bacteremia in acute bacterial prostatitis.ORDER REPORT TIME
Urinalysis Day 1 @ 13:40
Urine culture Day 2 @ 13:10
Urine gram stain Day 1 @ 13:30
Feedback3): The clock should be advanced "with the next available result" as the results of the urinalysis and gram stain will help guide further management. It is also reasonable to advance the clock directly to 13:40 or to initially advance the clock by performing additional physical examinations (not shown here).
Feedback4): Acute bacterial prostatitis can be diagnosed on clinical grounds alone, based on symptoms of painful urination, systemic symptoms (fever, malaise) and tender swollen prostate on exam. CBC and blood culture are often recommended to guide therapy. The most common cause is E. coli, however, a variety of pathogens may be responsible.
Treatment revolves around broad spectrum antibiotics. The drug therapy of choice is a quinolone (Ciprofloxacin). Trimethoprim-sulfamethoxazole is also an acceptable choice. In addition, general support measures such as analgesic & antipyretic (Acetaminophen), stool softner (Colace) and counseling should be provided.
ORDER
CBC with differential
Blood culture
Ciprofloxacin, oral, continuous
Acetaminophen, therapy, oral, continuous
Colace, oral, continuous
Reassure patient Counsel patient
Feedback5): Antibacterial therapy for acute bacterial prostatitis usually lasts 4 to 6 weeks. The patient should report improvement in symptoms within a few days. If the patient is septic (hypotensive), transfer to the hospital for intravenous antibiotics (gentamicin plus ampicillin). Follow-up with the patient can vary from a few days to a few weeks as there are no strict guidelines.
The patient is rescheduled for an appointment on Day 5 @ 10:00. This will advance the clock to Day 5 @ 10:00.
Feedback6): No additional end case orders are necessary in the time frame of this case.
Case 5: Complaint: Shortness of Breath Specialty: Medicine Topic: Pulmonology Setting: Ward
Case Summary
· 61-year-old hospitalized woman with shortness of breath.
· Vital signs show tachycardia (112 beats/min) and tachypnea (30/min).
· History reveals she was admitted 2 days ago for pneumonia. The shortness of breath began acutely and is associated with right sided chest pain that is worsened when taking a deep breath. She is on hormone replacement therapy.
· Examination shows loud S2 and right calf tenderness.
· Laboratory studies show elevated d-dimer, and spiral CT chest confirms pulmonary embolism.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: lung, heart, extremities · D-dimer · ECG · Spiral CT chest · PT/PTT · CXR· V/Q Scan · Exam: additional · Chest x-ray, portable · ABG· Cardiac enzymes · BNP - Brain natriuretic peptide · CBC · BMP - Basic metabolic profile
THERAPY · Oxygen · Heparin if stable· Thrombolytics if unstable · Intravenous access · Elevate head of bed · Nitroglycerin · Reassure patient · Coumadin
MONITORING · Pulse oximetry · Cardiac monitor · Vital signs · PT/PTT
LOCATION · Ward transfer to ICU
TIMING · Do not delay lungs and extremities exam.· For patients with high pretest probability of pulmonary embolism,spiral CT chest is recommended and quickest to diagnosis. Other options for diagnosis include ventilation-perfusion scan + d-dimer or pulmonary angiography.
SEQUENCING Orders Intravenous access, cardiac monitor, oxygen, pulse oximetry, elevate head of bed
Exam General, heart, lungs, extremities
Orders ECG 12 lead, ABG, chest x-ray portable, d-dimer, cardiac enzymes, BNP, CBC, BMP,nitroglycerin
Exam Skin, lymph nodes, HEENT, abdomen, rectal
Clock Advance to d-dimer result
Orders Spiral CT chest
Clock Advance to spiral CT result
Orders Heparin, PT/PTT, vital signs, reassure patient
Location Change to ICU
Clock Advance to case end
End Orders PT/PTT, coumadin
Feedback1): Initial vital signs show tachycardia and tachypnea. Prior to initiating a physical exam, it is important to order the following emergency management orders to treat and monitor the heart rate and oxygenation.
ORDER REPORT TIME
Pulse oximetry Day 1 @ 19:05
Cardiac monitor Day 1 @ 19:05
Oxygen
Intravenous access
Elevate head of bed
Feedback2): Once emergency management orders are placed, a brief examination focusing on "airway, breathing and circulation" should be performed. A lengthy examination should not be initially performed as it may waste valuable time, cause unnecessary delay in diagnosis and treatment, and cause harm to the patient.
Important aspects of the examination to note in this patient include:
General:
Degree of distress, cyanosis
Heart:
Elevated jugular venous pressure (Congestive heart failure)
S3 or S4 (Heart failure, Myocardial infarction)
Loud S2 (Sign of pulmonary hypertension)
Lungs:
Barrel chest, hyperressonance to percussion, vesicular breath sounds (COPD)
Coarse crackles (Bronchiectasis)
Rales (Congestive heart failure)
Pleural friction rub (may indicate pulmonary infarct)
Extremities:
Pain or tenderness (may be a sign of deep vein thrombosis)
Examination
General appearance
Chest/Lung
Heart/Cardiovascular
Extremities/Spine
Feedback3): In a hospitalized patient recovering from acute pneumonia, the following differential diagnoses should be considered in placing initial orders:· Pneumonia exacerbation - Chest X-ray· Pulmonary embolism o D-dimer - more useful to exclude PE if negative rather than include PE because it increases with many other disorders (e.g., metastatic cancer, trauma, sepsis, postoperative state).o ABG - may show decreased Pao2 & Paco2, increased pHo ECG - abnormal in 85% of patients with pulmonary embolismo Cardiac enzymes may show elevated troponin level because of right ventricular dilatationo Chest x-ray - often normal· Congestive heart failure - Chest x-ray, BNP (Brain natriuretic peptide)· Myocardial infarction - ECG, cardiac enzymes (Trial of nitroglycerin can also be diagnostically useful)· Anemia - CBC · COPD - Chest x-ray, ABG
ORDER REPORT TIME
ECG, 12 lead Day 1 @ 13:19
ABG - Arterial Blood Gas Day 1 @ 13:22
Chest X-ray, portable Day 1 @ 13:24
D-dimer, plasma Day 1 @ 13:34
Cardiac enzymes, serum Day 1 @ 14:04
BNP - Brain natriuretic peptide, serum Day 1 @ 14:04
CBC with differential Day 1 @ 13:34
BMP - Basic metabolic profile Day 1 @ 13:34
Nitroglycerin, sublingual, one time/bolus
Feedback4) Once initial orders have been placed, a more thorough examination can be performed to advance the clock while waiting for results.
Important aspects of the examination to note in this patient include:
Skin:
Diaphoresis (MI)
HEENT:
Fundoscopic exam - Papilledema (Hypertension)
Abdomen:
Hepatomegaly (CHF)
Rectal:
Bleeding may be a contraindication for potential blood thinning medications
Examination
Skin
Lymph nodes
HEENT/Neck
Abdomen
Rectal
Feedback5): For emergency cases, the clock should be advanced "with the next available result" as the results of individual tests may alter management.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 13:34.
Feedback6): The diagnosis of pulmonary embolism is based on a combination of clinical symptoms and diagnostic imaging. The gold standard is pulmonary angiography (3 hours), however the use of spiral CT (30 minutes) has become an excellent modality for diagnosing PE. Other imaging modalities include the ventilation-perfusion scan (2 hours) and doppler venous ultrasound of the lower extremities (2 hours). The following guidelines are generally accepted based on pretest probability. Criteria for determining pretest probability 1. PE more likely than alternatives: 3.0 points 2. Deep Vein Thrombosis (DVT) suspected: 3.0 points 3. Tachycardia (pulse >100 beats per minute): 1.5 points 4. Surgery or immobilization in last 4 weeks: 1.5 points 5. Prior DVT or Pulmonary Embolism: 1.5 points 6. Hemoptysis: 1.0 points 7. Active malignancy: 1.0 points Interpretation of pretest probability 1. Score 0-2 points: Low PE Probability (4% risk) 2. Score 3-6 points: Intermediate PE Probability (21% risk) 3. Score >6 points: High PE Probability (67% risk) · If high pretest probability - obtain spiral computed tomography of the chest. If positive, treat; If negative, obtain pulmonary angiography · If intermediate pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative, eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, treat. · If low pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative, eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, obtain pulmonary angiography. This patient would have a high pretest probability with a total of 9 points. Therefore, spiral CT is the best imaging modality choice for diagnosing pulmonary embolism.Positive D-dimer suggests PE more likely than alternative - 3 pointsPatient has calf tenderness with suspected DVT - 3 pointsTachycardia present - 1.5 pointsImmobilation from hospitalization for pneumonia - 1.5 points
ORDER REPORT TIME
Spiral computed tomography, chest Day 1 @ 14:04
Feedback7): The clock should be advanced to the results of the spiral CT. This can be done by advancing "With the next available result" or typing in the time to advance the clock to.
The clock will be advanced to reveal each result in chronological order. This will advance the clock to Day 1 @ 14:04.
Feedback8): The management of pulmonary embolism involves: Anticoagulation - can order heparin with PT/PTT monitoring or enoxaparin (low molecular weight heparin) without PT/PTT monitoring. The use of thrombolytics (urokinase or streptokinase) is advised in massive PE with hemodynamic instability, however they are controversial in normotensive patients.In addiiton, vital signs should be monitored and reassurance provided.
ORDER REPORT TIME
PT/PTT Day 1 @ 14:34
Vital signs Day 1 @ 14:07
Heparin, therapy, intravenous, continuous
Reassure patient 5 minutes
Feedback9): Patients receiving treatment for pulmonary embolism require constant and close monitoring, therefore the patient should be transferred to the ICU.
The patient is transferred to the ICU.
Feedback10): The clock should be advanced "with the next available result" to advance to additional results and any patient updates.
The clock will be advanced to reveal each result in chronological order. This will advance the clock.
Feedback11): Heparin therapy requires PT/PTT monitoring which should be ordered in advance. In addition, treatment with coumadin is an integral component of long term therapy for pulmonary embolism and should be ordered in advance.
ORDER
PT/PTT
Coumadin, oral, continuous starting from Day 3
Case 6: Complaint: Back pain Specialty: Medicine Topic: Rheumatology Setting: Office
Case Summary
· 67-year-old woman with back pain for two days.
· Vital signs are unremarkable.
· History reveals sharp, constant, localized lower back pain. Acetaminophen only partly relieves the pain. Menopause at age 54.
· Examination shows mild kyphosis, tenderness at L4.
· Imaging reveals L4 - L5 vertebral compression fractures; DEXA scan shows osteoporosis with a T score of -2.8.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: spine/extremities, neuro · Spine x-ray, lumbosacral · DEXA scan · Exam: HEENT, lymph nodes +/- complete · CBC · BMP · Phosphorus · LFT · TSH
THERAPY · Back brace · Acetaminophen with oxycodone · Calcium carbonate · Vitamin D · Alendronate · Advise patient, exercise program · Colace · Advise patient, rest at home · Raloxifene · Diet, high calcium · Physical therapy · Advise patient, estrogen replacement therapy · Advise patient, side effects of medication · Reassure patient
MONITORING · Not important in the time frame of this case
LOCATION · Office
TIMING · Do not delay spine x-ray, Dexa scan, pain relief, and osteoporosis treatment.
SEQUENCING Exam HEENT, lymph nodes, spine/extremities, neuro +/- complete
Orders Spine x-ray lumbosacral
Clock Advance clock to spine x-ray
Orders CBC, BMP, phosphorous, LFT, TSH, DEXA scan, back brace, advise patient rest at home, acetaminophen plus oxycodone, colace
Clock Advance clock to reschedule patient when all results are reported
Orders Calcium carbonate, vitamin D, alendronate, raloxifene, diet of high calcium, physical therapy, advise exercise, advise estrogen replacement, advise side effects, reassure
Clock Advance to case end
End Orders None
Feedback1): In an office based case with a patient who is hemodynamically stable, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional.
Important aspects of the physical exam in this patient include:
HEENT:
Goiter, exopthalmos - Hyperthyroidism
Lymph nodes:
Enlarged - lymphoma
Extremities/Spine:
Localized tenderness - fracture (osteoporosis) or lytic lesions (multiple myeloma)
Neuro/Psych:
Muscle weakness - Vitamin D deficiency
Shooting pain with straight leg raise - Disc herniation
The following examinations will be performed. Examinations you requested will be used in assessing your score, but results will not be reported. Only results for the following examinations will be reported.
Examination
General appearance
Skin
Breasts
Lymph nodes
HEENT/Neck
Chest/Lung
Heart/Cardiovascular
Abdomen
Genitalia
Rectal
Extremities/Spine
Neuro/Psych
Feedback2): In a post-menopausal woman with back pain, it is important to rule out a vertebral fracture. A plain film x-ray should be reviewed at this visit to look for the presence of a fracture which will guide further management.
ORDER
Spine x-ray, lumbosacral
Feedback3): In a post-menopausal woman with a vertebral compression fracture, osteoporosis is likely the most common underlying cause. However, routine laboratory tests should be performed to exclude other causes and secondary osteoporosis:
· CBC (may be abnormal in multiple myeloma or malignancy that has spread to the bone marrow)
· BMP (Calcium low in hypoparathyroidism and renal disease; calcium high in hyperparathyroidism and malignancy)
· Phosphorus, serum (Low in hyperparathyroidism, malignancy, hyperthyroidism; normal in osteomalacia)
· LFT (Abnormal in liver disease, metastatic disease and alcoholism that may present as osteoporosis)
· TSH (Hyperthyroidism)
In addition, evaluation for osteoporosis and treatment for the fracture should be initiated:
· DEXA scan
· Back brace - to immobilize the spine so it can heal
· Rest
· Acetaminophen with oxycodone - for pain relief since acetaminophen by itself only partially worked
· Colace - for constipation caused by the oxycodone
ORDER
CBC with differential
BMP - Basic Metabolic Profile
Phosphorus, serum
LFT - Liver function panel
TSH, serum, ultrasensitive
DEXA scan
Back brace
Advise patient, rest at home Acetaminophen with oxycodone, oral, continuous Colace, oral, continuous
Feedback4): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 10:45).
The patient will be rescheduled for an appointment on Day3 @ 11:00. This will advance the clock to Day 3 @ 11:00.
Feedback5): The diagnosis of osteoporosis is based on a T score of - 2.5 or lower on DEXA scan. Treatment for osteoporosis may vary depending on various guidelines, but can include:· Calcium carbonate - for prevention and treatment of osteoporosis· Vitamin D - for prevention and treatment of osteoporosis· Alendronate - for prevention and treatment of osteoporosis· Raloxifene - reduces risk of vertebral fractue 40-50%· Advise patient on estrogen replacement therapy (Raloxifene is a selective estrogen receptor modulator)· Advise patient, side effects of medication· Lifestyle changes: diet with high calcium, advise on exercise program, physical therapy(Calcitriol and Calcitonin are additional options, but studies show they are less effective than alendronate for vertebral osteoporosis)
ORDER REPORT TIME
Calcium carbonate, oral, continuous
Vitamin D, therapy, oral, continuous
Alendronate, oral, continuous
Raloxifene, oral, continuous
Diet, high calcium
Physical therapy Day 4 @ 11:00
Advise patient, exercise program 5 minutes
Advise patient, estrogen replacement therapy 5 minutes
Advise patient, side effects of medication 5 minutes
Reassure patient 5 minutes
Counseling orders must be ordered and performed separately on the USMLE CCS cases, however in this case simulation you may place multiple counseling orders simultaneously. Counseling orders will advance the clock to Day 3 @ 11:20.
Feedback6): Follow-up for osteoporosis varies depending on treatement. Early in treatment, the patient may be reviewed every three months. Later, the patient may be reviewed annually for yearly DEXA scan.
The clock will be advanced to the next result.
Feedback7): No additional end case orders are necessary in the time frame of this case. Besides for follow-up of symptoms and performance status every 3 months, a repeat radiograph and DEXA scan in one year are generally recommended for follow-up.
Case 7: Complaint: Fatigue Specialty: Medicine Topic: Endocrinology Setting: Office
Case Summary
· 42-year-old woman with fatigue for four months.
· Vital signs show BMI of 39.6 kg/m2.
· History reveals two previous urinary tract infections.
· Laboratory examination reveals an elevated fasting blood glucose and hemoglobin A1c.
Case Management By CCS Domains
OPTIMAL ORDERS ADDITIONAL ORDERS
DIAGNOSIS · Exam: HEENT, heart, rectal · BMP · Glucose, serum, fasting · Lipid profile · Hemoglobin A1c · Exam: complete · CBC · Urinalysis · Depression index · TSH · LFT · Magnesium · Urine microalbumin · ECG
THERAPY · Diet, low fat · Advise exercise program · Diet, diabetic · Diabetic teaching · Metformin · Aspirin · Lisinopril · Diet, calorie restricted · Consult, dietary · Consult, opthalmology · Consult, podiatry · Vaccine, influenza · Vaccine, pneumococcal · Advise side effects of medication · Advise medication compliance · Reassure
MONITORING · Hemoglobin AIc
LOCATION · Office · Admit if diabetic ketoacidosis or hyperosmolar nonketotic state present.
TIMING · Do not delay fasting glucose. · Order hemoglobin A1c after fasting glucose. · Do not delay diabetic education, diet and exercise recommendations.
SEQUENCING Exam HEENT, heart, abdomen, rectal, lymph nodes +/- complete
Orders CBC, BMP, TSH, glucose fasting, urinalysis, LFT, lipid profile, depression index, diet low fat, diet calorie restricted, advise exercise program
Clock Advance clock to reschedule patient when all results are reported
Orders Hemoglobin A1c, magnesium, urine microalbumin, ECG, consult opthalmology, consult dieatary, consult podiatry, diet diabetic, vaccine influenza, vaccine pneumococcal, diabetic teaching
Clock Advance clock to reschedule patient when all results are reported
Orders Metformin, aspirin, lisinopril, advise side effects, advise medication compliance, reassure
Clock Advance to case end
End Orders Hemoglobin A1c
Feedback1): In an office based case with a patient not in acute distress, it is appropriate to begin management with the physical exam. Points will likely be awarded to aspects of the physical exam that are most relevant, therefore a complete physical exam is optional. Important aspects of the physical exam in this patient include:HEENT: Enlarged thyroid - Thyroid abnormalityVision abnormalities - DiabetesPale conjunctiva - AnemiaHeart: Murmur - Hemolytic anemiaAbdomen:Abdominal mass - Renal cancerHepatomegaly - Liver diseaseRectal exam:Occult blood positive - Chronic blood loss, colon cancerLymph nodes:Enlarged - Metastatic cancer, lymphoma
Examination Time
General appearance 1 min
Skin 1 min
Breasts 1 min
Lymph nodes 1 min
HEENT/Neck 2 min
Chest/Lung 1 min
Heart/Cardiovascular 1 min
Abdomen 1 min
Rectal 2 min
Extremities/Spine 1 min
Neuro/Psych 1 min
Feedback2): Physical examination is non-specific, therefore important differential diagnoses to consider include: · Anemia (CBC) · Thyroid abnormalities (TSH) · Diabetes (fasting glucose) · Electrolyte abnormalities (BMP) · Renal disease (Urinalysis) · Liver disease (LFT) · Depression (Depression index) · Also, assessment of cardiac risk factors should be considered (Lipid profile). The patient is noted to be obese, therefore it is important to order lifestyle modifications with diet and exercise as outlined below.
The following key orders have been placed. Orders that you placed will be used in assessing your score but results will not be reported. Only results for the following orders will be subsequently reported.
ORDER REPORT TIME
CBC with differential Day 1 @ 14:13
BMP - Basic Metabolic Profile Day 1 @ 12:43
Urinalysis Day 1 @ 16:13
LFT Day 1 @ 12:43
Glucose, serum, fasting Day 1 @ 11:13
TSH, serum, ultrasensitive Day 3 @ 10:13
Lipid profile Day 3 @ 10:13
Depression index Day 1 @ 10:23
Diet, low fat
Diet calorie-restricted
Advise patient, exercise program 5 minutes
Counseling orders will advance the clock to Day 1 @ 10:18.
Feedback3): The patient should be rescheduled for an appointment once all results have been reported (after Day 3 @ 10:13).
Feedback4): The diagnosis of diabetes mellitus is based on the following criteria:· Random plasma glucose of 200mg/dL (11.1mmol/L) or higher, plus symptoms of diabetes · Fasting plasma glucose of 126mg/dL (7.0mmol/L) or higher · Plasma glucos