1. iStan®Simulation Exam VCU Internal Medicine M3 Clerkship

2. Scenario # 1 A 25 year-old man presents to the Emergency Department with sudden onset of shortness of breath. He has a history of asthma and occasionally uses an inhaler. He is very anxious and unable to speak in complete sentences. He appears exhausted. His vital signs are shown on the monitor.

3. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

4. Question #1 Which statement most accurately summarizes the pulmonary examination : A.The patient has egophony B.The patient has stridor C.The patient has wheezes D.The patient has crackles unilaterally E.The patient has bilateral crackles

5. Please review the CXR

7. Question #2 What is the most likely diagnosis? A. Acute coronary syndrome B. Asthma exacerbation C. Pulmonary embolus D. Panic attack E. Pneumonia

8. Question #3 What is the next best step in management of this patient? A. Administer oxygen and IV heparin B. Administer oxygen and an anxiolytic (e.g. lorazepam) C. Administer oxygen and albuterol via nebulization D. Administer oxygen and IV ceftriaxone E. Administer oxygen and IV magnesium

9. Question #4 What additional medication should be given at this time? A. Oral terbutaline B. Inhaled fluticasone C. Oral aspirin and IV metoprolol D. Oral prednisone E. Oral azithromycin

10. Please review the vital signs on the monitor Please re-examine the mannequin

11. Please Review the ABG

12. Question #5 Chose the most accurate interpretation of the ABG: A.Acute metabolic acidosis with hypoxia B.Acute respiratory acidosis with hypoxia C.Acute respiratory alkalosis with hypoxia D.Acute metabolic alkalosis with hypercapnia E.Acute metabolic acidosis with hypercapnia

13. Question #6 What is the next best step in managing this patient? A. Intubation and mechanical ventilation B. Administer IV methylprednisolone C. Administer activated protein C (drotrecogin alfa or Xigris TM ) D. Administer IV thrombolytics (e.g. tPA) E. Administer IV dobutamine

14. Case #2 A 55 year-old man with diabetes and hypertension awakes with dull pain in his epigastric area that has persisted for the past hour. He feels a little sweaty, nauseated, and lightheaded. His wife says that he’s had this pain several times in the past week. His other medical history is significant for prior peptic ulcer disease. Vitals signs and telemetry are shown on the monitor.

15. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

16. Please review EKG

18. Question #1 What is the most likely diagnosis? A. Viral gastroenteritis B. Recurrent peptic ulcer disease C. Acute pancreatitis D. Stable angina E. Myocardial infarction

19. Question #2 What is the next best step in this patient’s management? A. Administer IV fluids and IV anti-emetics B. Administer IV morphine and oxygen C. Administer IV esomeprazole, oxygen and oral sucralfate D. Administer oral aspirin, oxygen and IV heparin E. Administer oral aspirin, IV heparin, and IV metoprolol

20. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

21. Question #3 Which physical exam summary is most accurate? A. The patient has acute bronchospasm with wheezes B. The patient has bilateral crackles C. The patient has a diastolic murmur with left sided crackles D. The patient has a systolic murmur with bilateral crackles E. The patient has stridor

22. Question #4 What is the most appropriate next step? A. Upper endoscopy (EGD) B. Abdominal CT scan with contrast C. Cardiac catheterization D. Dobutamine stress test E. Antiarrythmics

23. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

24. Question #5 What are the most appropriate next steps? A. IV fluids and defibrillation B. IF fluids and antiarrythmics C. IV metoprolol and IV nitroglycerin D. IV fluids and IV atropine E. IV thrombolytics (e.g. tPA)

25. Case #3 A 75 year-old male nursing home resident is brought to the Emergency Department after he was noted to be less alert than usual. He has had a cough mildly productive of sputum and has complained of fevers. He had a stroke several years ago and is non-ambulatory. He has a prior history of alcohol abuse. His vital signs are shown on the monitor.

26. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

27. Question #1 Which physical examination finding summary is correct? A. The patient has bilateral wheezes B. The patient has stridor C. The patient has a systolic murmur D. The patient has right sided rales E. The patient has dry bilateral crackles

28. Please examine CXR on the monitor

30. Question #2 What is the most likely diagnosis? A. Myocardial infarction B. Bacterial COPD exacerbation C. Sepsis due to pneumonia D. Acute pancreatitis E. Acute PE

31. Question #3 What is the next best step in confirming the diagnosis? A. Obtain a chest CT B. Perform bronchoscopy with BAL C. Perform a thoracentesis D. Obtain sputum and blood cultures E. Obtain sputum, legionella and histoplasma urinary antigen tests

32. Question #4 What is the best initial management of this patient? A. Give albuterol via nebulization and oral prednisone B. Give IV heparin and oral aspirin C. Perform emergent cardiac catheterization D. Give IV vasopressors (e.g. norepinephrine) E. Give IV fluids and IV piperacillin/tazobactom and vancomycin

33. Please review vital signs on the monitor Please perform a cardiopulmonary examination of the mannequin

34. Question #5 What is the most appropriate management at this time? A. Intubation, mechanical ventilation, IV fluids and IV norepinephrine B. Noninvasive ventilation with BiPAP, escalate antibiotics and IV fluids C. Change the antibiotics to IV meropenem and azithromycin, give IV fluids D. Give IV methylprednisolone, IV fluids and IV norepinephrine E. Stabilize with IV fluids/pressors, order spiral CT scan