iStan®SimulationExam

VCU Internal Medicine M3 Clerkship

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.

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

Question #1

Which statement most accurately summarizes the pulmonary examination :

A. The patient has egophonyB. The patient has stridorC. The patient has wheezesD. The patient has crackles unilaterallyE. The patient has bilateral crackles

Please review the CXR

Question #2

What is the most likely diagnosis?A. Acute coronary syndromeB. Asthma exacerbationC. Pulmonary embolusD. Panic attackE. Pneumonia

Question #3

What is the next best step in management of this patient?A. Administer oxygen and IV heparinB. Administer oxygen and an anxiolytic (e.g. lorazepam)C. Administer oxygen and albuterol via nebulizationD. Administer oxygen and IV ceftriaxoneE. Administer oxygen and IV magnesium

Question #4

What additional medication should be given at this time?A. Oral terbutaline B. Inhaled fluticasoneC. Oral aspirin and IV metoprololD. Oral prednisoneE. Oral azithromycin

• Please review the vital signs on the monitor• Please re-examine the mannequin

Please Review the ABG

Question #5

• Chose the most accurate interpretation of the ABG:

A. Acute metabolic acidosis with hypoxiaB. Acute respiratory acidosis with hypoxiaC. Acute respiratory alkalosis with hypoxiaD. Acute metabolic alkalosis with hypercapniaE. Acute metabolic acidosis with hypercapnia

Question #6

What is the next best step in managing this patient?A. Intubation and mechanical ventilationB. Administer IV methylprednisoloneC. Administer activated protein C (drotrecogin alfa or XigrisTM)D. Administer IV thrombolytics (e.g. tPA)E. Administer IV dobutamine

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.

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

Please review EKG

Question #1

What is the most likely diagnosis?A. Viral gastroenteritisB. Recurrent peptic ulcer diseaseC. Acute pancreatitisD. Stable anginaE. Myocardial infarction

Question #2

What is the next best step in this patient’s management?A. Administer IV fluids and IV anti-emeticsB. Administer IV morphine and oxygenC. Administer IV esomeprazole, oxygen and oral sucralfateD. Administer oral aspirin, oxygen and IV heparinE. Administer oral aspirin, IV heparin, and IV metoprolol

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

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

cracklesD. The patient has a systolic murmur with bilateral

cracklesE. The patient has stridor

Question #4

What is the most appropriate next step?A. Upper endoscopy (EGD)B. Abdominal CT scan with contrastC. Cardiac catheterizationD. Dobutamine stress testE. Antiarrythmics

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

Question #5

What are the most appropriate next steps?A. IV fluids and defibrillationB. IF fluids and antiarrythmics C. IV metoprolol and IV nitroglycerinD. IV fluids and IV atropineE. IV thrombolytics (e.g. tPA)

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.

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

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

Please examine CXR on the monitor

Question #2

What is the most likely diagnosis?A. Myocardial infarctionB. Bacterial COPD exacerbationC. Sepsis due to pneumoniaD. Acute pancreatitisE. Acute PE

Question #3

What is the next best step in confirming the diagnosis?A. Obtain a chest CTB. Perform bronchoscopy with BALC. Perform a thoracentesisD. Obtain sputum and blood culturesE. Obtain sputum, legionella and histoplasma urinary antigen tests

Question #4

What is the best initial management of this patient?A. Give albuterol via nebulization and oral prednisoneB. Give IV heparin and oral aspirinC. Perform emergent cardiac catheterizationD. Give IV vasopressors (e.g. norepinephrine)E. Give IV fluids and IV piperacillin/tazobactom and vancomycin

• Please review vital signs on the monitor• Please perform a cardiopulmonary

examination of the mannequin

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