Feedback for Step 3 CCS Practice Cases

The links below provide feedback on diagnostic and management steps for the sample Step 3 Computer-Based Case Simulations. These also appear at the end of the practice cases.

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

Case 1

Feedback on a 65-year-old man presenting with acute chest pain and respiratory distress (10-minute case)

Case 2

Feedback on a 32-year-old woman presenting with knee pain and swelling (20-minute case)

Case 3

Feedback on a 65-year-old woman presenting with chest pain (20-minute case)

Case 4

Feedback on a 4-year-old boy presenting with shortness of breath (20-minute case)

Case 5

Feedback on a 31-year-old woman presenting with lethargy, nausea, and vomiting (20-minute case)

Case 6

Feedback on a 25-year-old pregnant woman presenting with a seizure and loss of consciousness (10-minute case)

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Orientation Feedback for Tension Pneumothorax (10-minute case)


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

In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress. Initially the presentation and reason for visit suggest a broad differential diagnosis, but the limited available history narrows the differential. The patient had an acute onset of right-sided chest pain 10 minutes before the ambulance arrived. He rates the pain as 8 on a 10-point scale. The pain is excruciating, sharp, and increases with respiration.

The patient appears pale and in marked respiratory distress. He is moaning and holding his hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low blood pressure. Physical examination shows no breath sounds and hyperresonance to percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The skin is pale, cool, and diaphoretic. The remainder of the physical examination is unremarkable. The patient's illness, at this point, seems most consistent with a pulmonary process.

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

Timely diagnosis and management are essential in this case. An optimal, efficient diagnostic approach would include quickly performing a targeted physical examination that includes chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen saturation with a pulse oximetry. Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment (eg, a 12-lead ECG, an arterial blood gas, or a portable chest x-ray) would be suboptimal in this case if ordered before the patient’s condition is stabilized.

As soon as the absent breath sounds are discovered, optimal treatment would include performing a needle thoracostomy followed by a chest tube insertion. A chest x-ray should be ordered to confirm appropriate tube placement and lung re-inflation. The patient’s blood pressure and respiratory rate should be closely monitored until the patient’s condition has stabilized.

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

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

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

In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible. Delaying diagnosis or treatment and pursuing alternate diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient. Other examples of treatments that would waste time, subject the patient to unnecessary discomfort or risk, and add no real benefit to this patient include:

  • CT before lung reinflation
  • Intubation
  • Pulmonary function testing
  • Thrombolytic therapy

Orientation Feedback for Rheumatoid Arthritis (20-minute case)


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

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

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

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

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

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

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

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

  • Chlamydia trachomatis tests
  • Neisseria gonorrhoeae tests
  • Antibody, anti-single-stranded DNA
  • Thyroid studies
  • Urinalysis
  • Uric acid, serum

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

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

  • Arthroscopy
  • Synovial biopsy

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

Orientation Feedback for Ascending Aortic Dissection (20-minute case)


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

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

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

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

An optimal, efficient approach would include performing a targeted physical examination (including cardiovascular, chest/lung, and neurologic/psychiatric examinations), ordering a 12-lead ECG, and a portable chest x-ray. Stabilizing the patient with intravenous (IV) beta blocker or an IV antihypertensive agent administration to decrease blood pressure, and IV narcotic analgesic administration to alleviate pain is important. The patient's cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs. Some measure of oxygen saturation is also indicated.

Once stable, some form of chest imaging that would reveal an aortic dissection (including CT of the chest with contrast, cardiac CTA with contrast, echocardiography, transesophageal echocardiography [TEE], MRI of the chest, or cardiac MRI with gadolinium) is needed. The diagnostic workup should also include blood tests for serum creatinine (basic metabolic profile or complete metabolic profile) to assess kidney function, electrolytes to check sodium and potassium concentrations, a complete blood count (CBC) to look for signs of anemia and infection, serum creatine kinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise, a D-dimer to rule out a pulmonary embolism, and a blood group and crossmatch. Some measure of oxygen saturation is also indicated.

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

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

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

  • Admitting the patient to the inpatient ward or intensive care unit
  • Angiocardiography, right and left sides of the heart
  • Antibiotics

Suboptimal management of this case would include ordering additional PE components that would add no relevant information, administering an IV antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in diagnosis or treatment. It would be suboptimal to order anything unnecessary that would waste time, even if the test or procedure were not invasive or risky (eg, lung scan).

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

Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:

  • Changing the location to the outpatient office or sending the patient home
  • Chest tube
  • Exercise ECG
  • Heparin
  • Laparotomy
  • Needle thoracostomy
  • Stress echocardiography
  • Thrombolytics
  • Warfarin

Orientation Feedback for Asthma (20-minute case)


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

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

Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild, intercostal retractions, hyperresonance on percussion, and bilateral expiratory wheezes with prolonged expiratory phase, and no crackles. HEENT/neck examination shows pale, boggy, edematous nasal mucosa without nasal flaring. Skin examination reveals dry scaly patches in the antecubital areas. The remainder of the physical examination is unremarkable. The patient's illness, at this point, would seem most consistent with an obstructive pulmonary disease process. In this case, the increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma.

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

An optimal, efficient approach would include performing a targeted physical examination (including HEENT/neck, chest/lung, cardiovascular, and abdominal examinations) and addressing oxygen status by ordering pulse oximetry or oxygen therapy. Treating the patient’s respiratory distress with optimal inhalation (IN) bronchodilators (such as albuterol or levalbuterol), as well as optimal oral (PO) steroids, is essential.

The diagnostic workup should also include counseling the patient/family about asthma care or the side effects of medication. Monitoring the patient’s respiratory status by ordering a chest/lung examination after treatment is also important.

In this acute presentation, timing is important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible (ie, during the first 12 hours of simulated time).

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

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

Suboptimal management of this case would include administering a bronchodilator by a suboptimal route (such as intramuscular (IM), PO, or subcutaneous (SQ)); or administering a suboptimal bronchodilator (such as atropine or aminophylline); monitoring the patient by ordering arterial blood gas analysis instead of a chest/lung examination after treatment; failing to counsel the patient/family; or a delay in diagnosis or treatment.

Examples of poor management would include failure to order a physical examination, failure to administer a bronchodilator, and failure to address the patient’s oxygen status.

Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:

  • Antibiotics
  • Bronchoscopy
  • Chest CT
  • Endotracheal intubation
  • Intravenous sympathomimetics

Orientation Feedback for Diabetes with ketoacidosis; E. coli sepsis (20-minute case)


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

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

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

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

An optimal, efficient approach would include performing a targeted physical examination (including chest/lung, cardiovascular, abdominal, and neurologic/psychiatric examinations), and ordering a serum glucose test using a glucometer and a urinalysis or complete blood count (CBC) to check for signs of infection. Stabilizing the patient with optimal intravenous (IV) fluids (eg, lactated ringer solution or normal saline solution) to improve hydration, and treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotics to cover the most likely sources of infection are important. Once the serum glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical. The patient’s cardiovascular status should be monitored by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit.

The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism, and serum electrolyte measurements (ie, potassium) to assess the severity of dehydration. Serum creatinine or urea nitrogen measurements (basic metabolic profile or complete metabolic profile) to assess kidney function are indicated. Continued monitoring of the patient’s serum glucose, electrolytes, particularly potassium, and arterial blood pH after treatment is also important.

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

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

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

Suboptimal management of this case would include ordering additional PE components that would add no relevant information; delay in diagnosis or treatment; administering suboptimal IV fluids (eg, hypotonic saline solutions, dextrose in water, or dextrose in lactated ringer); initial treatment with subcutaneous (SQ) insulin; suboptimal IV or IM antibiotics; or neglecting to order indicated blood tests. It would be suboptimal to order unnecessary tests or procedures that would serve no clear diagnostic or therapeutic purpose even if those actions are low-risk.

Examples of poor management would include failure to order any physical examination; failure to order a serum glucose test; failure to order a blood culture to determine the cause of the infection; failure to treat with IV fluids, antibiotics, and insulin; or failure to monitor the patient after treatment.

Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk or would add no useful information to that available through safer or less invasive means include:

  • Gastric lavage
  • Upper gastrointestinal endoscopy

Orientation Feedback for Eclampsia; Fetal Distress (10-minute case)


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

In this case, a 25-year-old woman at 38 weeks’ gestation comes to the emergency department after suffering a seizure with loss of consciousness about 10 minutes earlier. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient is gravida 1, para 0, and has been receiving routine prenatal care. The pregnancy has been uncomplicated so far. She has had a severe headache for the past 3 days, and her feet have appeared swollen during the past 2 to 3 weeks. She has never had a seizure, and there is no history of hypertension or renal or neurologic disease. The patient is conscious but appears confused.

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

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

An optimal, efficient approach would include performing a targeted physical examination (including skin, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, extremities, and neurologic/psychologic examinations) and ordering a complete blood count (CBC) to rule out hemolysis. Stabilizing the patient with intravenous (IV) magnesium sulfate to prevent another seizure, plus an IV optimal antihypertensive (hydralazine or betablockers) to reduce blood pressure, is important. Once the patient’s condition is stabilized, it is imperative to deliver the fetus quickly either by stimulating contractions using optimal oxytocics, by performing a cesarean delivery, or by consulting obstetrics/gynecology. The fetal heart rate should be watched until delivery by ordering a fetal monitor. Some measure of patient’s urine output is also indicated.

The diagnostic workup should also include a urinalysis and blood tests for the following: serum creatinine or blood urea nitrogen (basic metabolic profile or comprehensive metabolic profile) to assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes; PT/PTT; and platelet count to rule out disseminated intravascular coagulation

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

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

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

Suboptimal management of this case would include: ordering a peripheral smear instead of a complete blood count to rule out hemolysis; administering intramuscular or IV phenobarbital or benzodiazepine instead of IV magnesium sulfate; administering any IV antihypertensive other than IV hydralazine or an IV beta blocker; stimulating contractions using suboptimal oxytocics; failing to monitor the patient’s urine output; or a delay in diagnosis or treatment.

Examples of poor management would include failure to order a neurologic/psychiatric examination, failure to administer an antihypertensive agent, failure to monitor the fetus or mother after delivery, or administering a suboptimal seizure medication (phenobarbital).

Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:

  • Changing the location to the outpatient office or sending the patient home
  • Mifepristone
  • Abdominal CT