Select Start Case to begin

1. Select Start Case to begin Maximum allotted case time 20 minutes + 5 minutes for case end orders Warning: Select anything on the screen other than start case may result in unrecoverable data and time loss This case may take 3 minutes to load Do not select “Next” unless instructed S.S.Patel Next

2. OK Day 1: 10:00 am A 65-years old male comes to the emergency room with c/o chest pain Click here

3. OK Day 1: 10:00 am A 65-years old male comes to the emergency room with c/o chest pain & shortness of breath. Symptoms started when patient was watching TV in his home. It is squeezing chest pain radiating to his jaw and left shoulder. Pain is constant, no change in pain with respiration, not reproduce by palpation. 8/10 in severity. He is still in pain. He is also feeling short of breath.Physical examination revealed normal heart sound. PMH: negative FH: h/o heart disease in family Social History: smoking one pack of cigarette for last 40 years There may be more information on the real exam usually but I’ve written only relevant points here. On the exam, you must have formulated your differential diagnosis by this time. Most of the cases are straight forward and usually less than three differential diagnosis if not straight forward. Click here

4. Click here OK Vitals: Temp – 98.70 F Pulse – 100 RR – 17 BP – 100/76 Up to this, you just click OK on the real exam. Once you click OK here, you are on your own. You need to take decision from here what you want to do with this patient

5. Click here PE or Interval History Obtain lab results or see the patient later Patient Location Order This exam gives score according to the step you are taking in the patient’s care. It is not necessary to do physical examination first all the time. Atleast for this exam! So depending upon patient’s condition, you can write order first or start examination first. We all have nearly similar knowledge but software is the way to check how we apply our knowledge when it comes to patient’s care. If you follow standard protocol, you won’t have any problem on the real exam. Select an option above

6. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Input: Confirm Order Cancel Click here You can write everything at the same time or enter the order individually. When you click “Confirm Order”, It will ask you to verify your order by giving all available options for your order. For example: If you have written EKG, it may show you following options. EKG, 12 lead EKG, ambulatory EKG, monitor EKG, rhythm EKG, stress test USMLE software give all available option from first 3 letters you have entered O-SAT Oxygen (patient is short of breath) IVA EKG ASPIRIN Nitroglycerin Cardiac monitor

7. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Oxygen Saturation

8. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat Oxygen saturation Frequency Every: Hour

9. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Oxygen

10. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Frequency One time/Bolus: Continuous: Confirm Order Cancel Click here Route Inhalation Oxygen

11. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here IV Access

12. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat IV Access Frequency Every: Hour

13. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here EKG EKG, 12 lead EKG, ambulatory EKG, monitor EKG, rhythm EKG, stress test

14. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat EKG, 12 leads Frequency Every: Hour

15. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Monitor, cardiac There will be a list of many things under monitor like monitor, fetal external; monitor, EKG, etc.

16. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat Monitor, cardiac Frequency Every: Hour

17. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Aspirin

18. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Frequency One time/Bolus: Continuous: Confirm Order Cancel Click here Route IV Oral Aspirin

19. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Nitroglycerin

20. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: One time/Bolus: Continuous: Confirm Order Cancel Click here Route IV Sublingual Nitroglycerin Nitroglycerin can be used as IV, oral, topical and sublingual Frequency

21. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report After you complete Ordering process (order input, order verification & order qualifier), you will see summary of your orders here with reporting time which will help you to advance the clock to see available lab results

22. History Interval / Follow up Physical Examination Complete (order vitals from order sheet) General appearance Head & Neck Chest / Lung Cardiovascular Skin Lymphnode PE or Interval History Obtain lab results or see the patient later Patient Location Order Abdomen Genitalia Rectal Neuro exam Extremities & Spine Breast Click OK after you’ve selected the exam you want Ok Cancel

23. Confirm H&P Choices: Ok Cancel PE or Interval History Obtain lab results or see the patient later Patient Location Order Physical Examinations General appearance………………………………1 min Chest / Lung……………………………………… 1 min CVS………...……………………………………… 1 min Total minutes: 3 mins This will advance your clock to: Day 1@10:07 am Click OK will advance your clock and will give you result of examination you have selected

24. PE or Interval History Obtain lab results or see the patient later Patient Location Order History & Physical: Click here Ok Cancel You will see physical exam findings here. Signs are usually straight forward according to case. I have written only relevant information here. For this Case findings will be as follow: General Appearance: appears in severe pain, looks pale and diaphoretic CVS: tachycardia, no murmur, gallop, JVD Lung: CTA B/L

25. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report After you complete Ordering process (order input, order verification & order qualifier), you will see summary of your orders here with reporting time which will help you to advance the clock to see available lab results

26. PE or Interval History Obtain lab results or see the patient later Patient Location Order Click here Schedule Appointment On In With next available result Call/see me as needed Days Hours Mins Add 10 mins Ok Cancel

27. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report By advancing clock to 10 mins, you will see the result of test that will be available in 10 mins. Once you see all result, you need to write order again as you did before. For this case, you will get result of O-SAT, EKG. So after you look at the results, you need to click on order to write new order.

28. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Input: Confirm Order Cancel Click here Cardiac enzymes CBC BMP CXR Morphine (patient is in severe pain)

29. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Cardiac enzymes, serum

30. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat Cardiac enzymes, serum Frequency Every: 8 Hour

31. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here CBC

32. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat CBC Frequency Every: Hour

33. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here CXR CXR, PA/Lateral CXR, PA CXR, portable, PA CXR, oblique CXR, right lateral decubitus CXR, left lateral decubitus

34. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat CXR, PA/Lateral Frequency Every: Hour

35. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here BMP

36. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: Confirm Order Cancel Click here Urgency Stat BMP Frequency Every: Hour

37. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Verification: Confirm Order Cancel Click here Morphine Morphine sulfate Morphine, sustained-release Morphine, urine

38. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Qualifier: One time/Bolus: Continuous: Confirm Order Cancel Click here Route IV Oral Morphine Morphine can be used as IV, Oral, IM and SC Frequency

39. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report After you complete Ordering process (order input, order verification & order qualifier), you will see summary of your orders here with reporting time which will help you to advance the clock to see available lab results

40. PE or Interval History Obtain lab results or see the patient later Patient Location Order Click here Schedule Appointment On In With next available result Call/see me as needed Days Hours Mins Add 10 mins Ok Cancel

41. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report By advancing clock to 10 mins, you will see the result of test that will be available in 10 mins. Once you see all result, you need to click on patient location to move the patient in the ward. For this case, you will get result of EKG, CXR. So after you look at the results, you need to click on patient location to move the patient in the ward.

42. PE or Interval History Obtain lab results or see the patient later Patient Location Order Click here Emergency Room Office Home ICU Ward Close

43. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Review: Confirm Move Cancel Click here You will see all orders that are pending. When you click “Confirm Move” It will show you the vitals for that time. Now patient is in the ward so to move on this case, you need to enter new orders

44. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Input: Confirm Order Cancel Click here Once you click on “confirm order” it will follow the same way as you have enter order before. Bed rest NPO Nitroglycerin Metoprolol Heparin Lipid profile (it’s not necessary to order now)

45. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report After you complete Ordering process (order input, order verification & order qualifier), you will see summary of your orders here with reporting time which will help you to advance the clock to see available lab results.

46. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order Input: Confirm Order Cancel Click here Once you click on “confirm order” it will follow the same way as you have enter order before. Vitals (remember this is a MI patient so you need to monitor his vitas frequently)

47. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report After you complete Ordering process (order input, order verification & order qualifier), you will see summary of your orders here with reporting time which will help you to advance the clock to see available lab results.

48. PE or Interval History Obtain lab results or see the patient later Patient Location Order Click here Schedule Appointment On In With next available result Call/see me as needed Days Hours Mins Add 30 mins Ok Cancel

49. PE or Interval History Obtain lab results or see the patient later Patient Location Order Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Click here Order Route/Urgency Frequency Time Order Time Report By advancing clock to 30 mins, you will see the result of test that will be available in 30 mins. Once you see all result, you need to write order again as you did before. For this case, you will get result of CBC, BMP, Vitals. So after you look at the results, Now it is time to ask the patient how he is feeling.

50. History Interval / Follow up Physical Examination Complete (order vitals from order sheet) General appearance Head & Neck Chest / Lung Cardiovascular Skin Lymphnode Click here PE or Interval History Obtain lab results or see the patient later Patient Location Order Abdomen Genitalia Rectal Neuro exam Extremities & Spine Breast Ok Cancel