Each CCS case is a dynamic, interactive simulation of a patient-care situation designed to evaluate your approach to clinical management, including diagnosis, treatment, and monitoring. The cases provide a means for observing your application of medical knowledge in a variety of patient care situations and settings over varying periods of simulated time. As simulated time passes, a patient's condition may change based on the course of the underlying medical condition(s), or your management, or both. Patients may present with acute problems to be managed within a few minutes of simulated time or with chronic problems to be managed over several months of simulated time. 

The cases used in the CCS portion of the Step 3 examination are based upon a CCS examination blueprint. The blueprint defines the requirements for CCS examination forms. The CCS blueprint is used to construct CCS examination forms focusing primarily on presenting symptoms and presenting locations. Presenting symptoms are related to the USMLE Content Outline and include, but are not limited to, problems of the circulatory, digestive, renal/urinary, endocrine/metabolic, behavioral/emotional, respiratory, and reproductive systems. Presenting locations include the outpatient office, emergency department, inpatient unit, intensive care unit, and the patient's home.

You will manage patients using the Primum software. Information about a patient's condition will be displayed on the computer screen. At the start of each case, you will receive a brief description of the reason for the encounter and the patient's appearance and status along with the vital signs and history. You must initiate appropriate management and continue care as the patient's condition changes over simulated time. Patient information will be provided to you in response to your requests for interval history and physical examination findings, tests, therapies, and procedures. Requests for interval history and physical examination automatically advance the clock in simulated time. To see results of tests and procedures and to observe effects of treatment, you must advance the clock in simulated time.

Physical examination should be ordered if and when you would do the same with a real patient. You can begin management by selecting the desired components of a physical examination, writing orders before examining a patient, changing the patient's location, or advancing the clock in simulated time. If physical examination reveals findings that you believe render selected orders inappropriate, and the orders have not yet been processed, you can cancel those orders by clicking on the order and confirming the cancellation. At subsequent intervals of your choosing, you can also request interval histories, which are analogous to asking the patient, "How are you?" 

You will provide patient care and management actions by typing on the order sheet section of the patient chart. The order sheet enables you to request tests, therapies, procedures, consultations, and nursing orders representing a range of diagnostic and therapeutic management options. It is also your means of giving advice or counseling a patient (eg, "smoking cessation," "low-fat diet," "safe-sex techniques"). The order sheet has a free-text entry format; you can type whatever you want. It is not necessary, however, to type commands (eg, "administer," "draw"). The "clerk" recognizes thousands of different entries typed in different ways. As long as the clerk recognizes the first three characters of the name or acronym (eg, "xra," "ECG"), you will be prompted for clarification and shown a list of orders beginning with those three characters. 

Note: You can place orders only in the order sheet section of the patient chart. You cannot place orders on any other section of the chart (ie, Progress Notes, Vital Signs, Lab Reports, Imaging, Other Tests, Treatment Record). 

In some locations (eg, the office, the inpatient unit), there may be cases where a patient already has orders on the order sheet at the beginning of the case. In these situations, the existing orders will be displayed on the order sheet (eg, "oral contraceptive") with an order time of Day 1 @00:00. You must decide whether to continue or cancel the orders as you deem appropriate for the patient's condition; these orders remain active throughout the case unless canceled. 

Advancing the clock is what "makes things happen." You must advance the clock in simulated time to see results of tests and procedures, and to observe effects of treatment. After you enter and confirm all the orders you deem appropriate at a given time, you will see report times displayed on the order sheet. You must advance the clock to the indicated report times or the next time you wish to evaluate the patient in order to receive the study result and observe the effect of therapies. Note: In CCS numeric lab tests, normal ranges are included with the results; these normal ranges may differ slightly from those in the MCQ portion of the examination. 

As simulated time passes, you might receive notification of change in a patient's condition through messages from the patient or the patient's family or from other health care providers if the patient is in a setting such as the hospital. You decide whether these messages affect your management plan. 

Note that if a clock advances to a requested appointment time is stopped for any reason, the requested appointment is canceled. Also note that if you advance the clock in simulated time and no results are pending, the case will advance to the next patient update or to the end of the case. Cases end under different circumstances and after varying amounts of simulated and real time. A case will end when you reach the maximum allotted real time. Alternatively, a case may end when you have demonstrated your skills sufficiently. Encountering the Case-end Instructions screen before you think you are finished managing a patient does not necessarily mean you did something right or wrong. Once you are prompted with the Case-end Instructions screen, real time permitting, you will have a few minutes to finalize your orders and review the chart. At this point you can cancel orders and add new ones. Note that after receiving the Case-End instructions screen, you cannot order physical examination components, change the patient's location, order a follow-up appointment, or see the results of any pending tests. After finalizing patient care, you must select Exit Case to exit the case. 

If a case has not ended and you feel you have finished management of the case, you can end it by advancing simulated time. Use the clock as you normally would to receive results of pending tests and procedures. Once there are no longer any pending patient updates, tests, or procedures, use the clock to advance simulated time until the case ends.

Simulated patients may be from any age group, ethnicity, or socioeconomic background and may present with well-defined or poorly defined problems. Patients may present with acute or chronic problems, or they may be seeking routine health care or health maintenance with or without underlying conditions. Assume that each patient you are managing has already given his or her consent for any available procedure or therapy, unless you receive a message to the contrary. In the case of a child or an infant, assume the legal guardians have given consent as well.

In the CCS health care network, you have an outpatient office shared with colleagues across specialty areas. Your office hours are Monday through Friday from 09:00 to 17:00. The hospital facility, a 400-bed regional referral center with an emergency department, is available 24 hours a day. Standard diagnostic and therapeutic options are available; no experimental options are available. The emergency department is a 24-hour facility, and the intensive care unit is available for medical (including coronary), surgical, obstetric, pediatric, and neonatal patients. At the start of each case, you will be informed of the presenting location. You should change a patient's location as you deem appropriate. 

Surgical and labor/delivery facilities are available as well as both inpatient and outpatient laboratory and imaging services; however, you cannot transfer patients to these locations directly. CCS staff will arrange for transfer of patients to these locations for you.

CCS measures those skills a physician demonstrates in managing a patient over time with the notable exception of skills that require human interaction (eg, history taking, physical examination, providing emotional support, etc.). Specific measurement objectives, designed as part of each case simulation, assess competency in managing a patient with a particular problem or health care need in the context of a specific health care setting. 

The timing and sequencing of indicated actions, as well as the commission of actions that are not indicated or are potentially harmful, are aggregated in your evaluation. Indicated patient management actions are awarded credit while actions that are not indicated and pose greater potential risk to a patient decrease your score. Seemingly correct management decisions made in an incorrect sequence or after a delay in simulated time may receive no credit. Note that some orders (eg, counseling, diet, ambulation) tend to carry little or no weight in scoring unless they are particularly relevant to the case (eg, specific diet orders for a patient with diabetes). 

Management of patients consistent with widely accepted standards of care will achieve a high score, although multiple correct approaches may exist. Note that in some cases there may be very little for you to do to manage a patient. In those instances, you will be scored on your ability to recognize situations in which the most appropriate action is to refrain from, or defer, testing and treatment. You will be scored lower if you take an aggressive approach when restraint and observation are the standard of care. The best overall strategy is to balance efficiency with thoroughness based upon your clinical judgment. 

Cost is accounted for indirectly based on the relative inappropriateness of patient management actions. If you order something that is unnecessary and excessive, your score will decrease. In considering various options including the location in which you manage the patient, you need to decide whether the additional cost is warranted for better patient care. 

The scoring process uses algorithms that represent codified expert physician-defined criteria. These criteria allow for variations in care protocols among health care settings and systems. The performance criteria are obtained from expert physicians who are experienced in training physicians and in caring for patients. For each case, the input of expert generalists and specialists is obtained to ensure that performance criteria are reasonable for any general, undifferentiated physician practicing medicine in an unsupervised setting.

In the simulation, you should function as a primary care physician who is responsible for managing each simulated patient. Management involves addressing a patient's problem(s) and/or concern(s) by obtaining physical examination results, diagnostic information, providing treatment, monitoring patient status and response to interventions, scheduling appointments and, when appropriate, attending to health maintenance screenings and patient education. You will manage one patient at a time and should continue to manage each patient until the end-of-case screen is displayed.

In the generalist role, you must manage your patient in both inpatient and outpatient settings. Sometimes this may involve management in more than one location—initially caring for a patient in the emergency department, admitting the patient to the hospital, and discharging and following the patient in the outpatient setting. 

You should not assume that other members of the health care team (eg, nurses, consultants) will write or initiate orders for you. Some orders (eg, "vital signs" at the beginning of a case and upon change of location) may be done for you, but you should not make assumptions regarding other orders. For example, orders usually requested to monitor a patient's condition, such as a cardiac monitor and pulse oximetry, are not automatically ordered. You are responsible for determining needs and for making all patient management decisions, whether or not you would be expected to do so in a real-life situation (eg, ordering IV fluids, surgical procedures, or consultations). If you order a procedure for which you are not trained, the medical staff in Primum cases will either assist you or take primary responsibility for implementing your request. 

As in real life, consultants should be called upon as you deem appropriate. Typically, consultants are not helpful since computer-based case simulations are designed to assess your patient management skills. However, requesting consultation at appropriate times may contribute to your score. In some cases, it may be necessary to implement a course of action without the advice of a consultant or before a consultant is able to see your patient. In other cases, a consultant may be helpful only if called after you have obtained enough information to justify referring the patient to his or her care.

Orientation Feedback for Tension Pneumothorax

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

In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress. 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 an 8 on a 10-point scale. The pain is excruciating, sharp, and increases with respiration.

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

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

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 by pulse oximetry. Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment (eg, a 12 lead ECG, arterial blood gases, 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 and exam findings consistent with tension pneumothorax are discovered, optimal treatment would include performing a needle thoracostomy for decompression followed by a chest tube insertion for lung reexpansion. A chest x-ray should be ordered to confirm appropriate tube placement and lung reexpansion. 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 or 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 thoracostomy, delay in treatment to reexpand the lung, or absence of 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 alternative 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 reexpansion
• Intubation
• Pulmonary function testing
• Thrombolytic therapy

Orientation Feedback for Rheumatoid Arthritis

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

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

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

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

An 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. Optimal treatment would include a combination of a nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid with a disease-modifying antirheumatic drug (DMARD) for comprehensive therapeutic treatment. Administration of a DMARD, eg, methotrexate or etanercept, prevents or slows joint damage, and improves joint function. An NSAID or corticosteroid relieves pain and decreases inflammation essential to provide interim symptom relief while the selected DMARD takes effect. 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.

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. With the availability of effective treatment for rheumatoid arthritis and concerns about opioid addiction, narcotic analgesics should have a limited role in treatment.

Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information 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

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

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

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

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

An optimal, efficient approach would include performing a targeted physical examination (including cardiovascular, chest/lung, and neurologic/psychiatric examinations), ordering a 12 lead electrocardiography (ECG), and a portable chest x-ray. Optimal medical therapy would include stabilizing the patient with intravenous (IV) medications to lower both blood pressure and heart rate. Suboptimal treatment would include other antihypertensive agents. Lastly, 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 assess for an aortic dissection (including computed tomography (CT) of the chest with contrast, cardiac computed tomography angiography (CTA) with contrast, echocardiography, transesophageal echocardiography (TEE), magnetic resonance imaging (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, serum creatine kinase or serum troponin I (cardiac enzymes) to rule out myocardial compromise, and a blood group and crossmatch.

Once the ascending aortic dissection is discovered and aortic root involvement confirmed, optimal treatment should include open heart surgery, endovascular aortic aneurysm repair (EVAR), thoracotomy or cardiothoracic 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
• Antibiotics

Suboptimal management of this case would include ordering additional physical examination 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 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

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

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

Physical examination shows slight tachycardia. Chest/lung examination reveals bilateral, mild, intercostal retractions, and bilateral expiratory wheezes with prolonged expiratory phase, and no crackles. HEENT/neck examination shows pale, boggy, edematous nasal mucosa without nasal flaring. Skin examination reveals dry, scaly patches in the antecubital areas. 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 bronchodilators (such as albuterol or levalbuterol), as well as optimal oral (PO) steroids, is essential.

Optimal management should also include counseling the patient/family about asthma care and the side effects of medication. Monitoring the patient’s respiratory status by ordering a 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 few 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 or oral); 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

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) antibiotic 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 before administering empiric antibiotics, 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 delay in diagnosis or treatment; administering suboptimal IV fluids (eg, hypotonic saline solutions, dextrose in water, or dextrose in Lactated Ringer solution); initial treatment with subcutaneous 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 or failure to order a blood culture before administering empiric antibiotics; 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

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 no previous history of seizures, and there is no history of hypertension or renal or neurologic disease. The patient is conscious but appears confused.

Physical examination shows tachycardia, a low-grade fever, and elevated blood pressure. Cardiovascular examination shows a loud S4 and bounding central and peripheral pulses. There is a grade 2/6 systolic ejection murmur at the left sternal border without radiation. There is marked vasospasm on funduscopic examination with normal disc margins and a minor tongue laceration. Abdominal examination shows a gravid uterus with a fundal height of 37 cm. Estimated fetal weight is 2700 g (6 lb). The fetus is cephalic by palpation with a fetal heart rate of 144 beats/min. Genital examination reveals an edematous vulva. The cervix is dilated to 1 cm and 50% effaced. Extremities/spine examination shows 4+ pitting edema in both lower extremities to the 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 beta blockers) to reduce blood pressure, is important. Once the patient’s condition is stabilized, it is imperative to deliver the fetus either by stimulating contractions using optimal uterotonics, 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 the patient’s urine output is also indicated.

The diagnostic workup should also include a urinalysis and blood tests for the following: serum creatinine or urea nitrogen (basic metabolic profile or comprehensive metabolic profile) to assess kidney function; electrolytes to check sodium and potassium levels; liver enzymes; and platelet count to diagnose HELLP syndrome.

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

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, 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 PO
• CT, abdomen/pelvis
• Carboprost IM
• Alprostadil IV
• Dilatation and curettage