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The program is smooth, it has no delay; the patient updates are seamless, and there is real-time, interactive feedback based on your responses. This is similar to what is graded on the real test. 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 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:.
Orientation Feedback for Diabetes with ketoacidosis; E. In this case, a 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 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. Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses.
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.
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 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.
An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first hour of simulated time. 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:.
Orientation Feedback for Eclampsia. 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 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 g 6 lb. Genital examination reveals an edematous vulva. 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.
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.
The fetal heart rate should be watched until delivery by ordering a fetal monitor. 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. Computer-based Case Simulations.
Step 1 Materials. Step 2 CK Materials. Step 3 Materials. Introduction This overview, in combination with Common Questions , software instructions, and practice cases is intended to prepare you for an examination that includes Computer-based Case Simulations CCS software.
Path 4. CSS Overview. Evaluative Objectives and Assessment of Your Performance. Case 1: Feedback on a year-old man presenting with acute chest pain and respiratory distress minute case. 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.
Score Report. Attempt Limit. Where can I get sample test materials to practice taking a test? Who can I talk to if I have trouble installing or using practice materials? Free Download Here. Sign in. Log into your account. Forgot your password?
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