1. S.S.Patel 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 Next

2. Day 1: 10:00 am A 60-years old male comes to your office for refilling of his hypertension medicine OK Click here

3. Day 1: 10:00 am A 60-years old male comes to your office for refilling of his medication for hypertension. In your office, he suddenly develop severe chest pain. Patient describes pain as tearing chest pain. 9/10 in severity. He has not been taking his medicine for HTN regularly. Physical examination revealed unequal blood pressure in both arms. PMH: h/o HTN for last ten years Social History: smoking one pack of cigarette for last 20 years OK Click here 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.

4. Vitals: Temp – 97.8 0 F Pulse – 115 RR – 19 BP – 190/110 OK Click here 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. PE or Interval History Order Obtain lab results or see the patient later Patient Location Select an option above Click here 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.

6. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Input: Confirm OrderCancel O-SAT IVA Oxygen EKG Transfer to ER (you can do that by clicking on patient location so do not need to write here in order) 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 Click here Once you click on “confirm order” it will follow the same way as you have already seen in other cases before. So I haven’t gone through all orders as I did before

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

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

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

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

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

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

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

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

15. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records 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 Click here

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

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

18. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Input: Confirm OrderCancel Propranolol ASPIRIN Morphine Cardiac monitor Cardiac enzymes Vitals CBC BMP CXR 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 Click here Once you click on “confirm order” it will follow the same way as you have already seen in other cases before. So I haven’t gone through all orders as I did before

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

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

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

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

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

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

25. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records 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 Click here

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

27. Confirm H&P Choices: OkCancel PE or Interval History Order Obtain lab results or see the patient later Patient Location Physical Examinations General appearance………………………………1 min Head & Neck……………………………………… 2 mins Chest / Lung……………………………………… 1 min CVS………...……………………………………… 1 min Abdomen..………………………………………… 1 min Total minutes: 6 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

28. History & Physical: OkCancel PE or Interval History Order Obtain lab results or see the patient later Patient Location 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: patient in severe pain CVS: murmur of aortic regurgitation Lung: CTA B/L HEENT: no JVD ABD: BS (+), spleen & liver not enlarged Click here

29. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records 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 Click here

30. Schedule Appointment On In With next available result Call/see me as needed PE or Interval History Order Obtain lab results or see the patient later Patient Location SonMonTueWedThuFriSat 1234567 891011121314 15161718192021 22232425262728 DaysHoursMins OkCancel Click here Add 15 mins

31. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records 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 cardiac monitor, vitals, CBC, BMP and CXR. So after you look at the results, you need to click on order to write new order. Click here

32. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Input: Confirm OrderCancel Chest CT scan Bed rest Click here Once you click on “confirm order” it will follow the same way as you have already seen in other cases before. So I haven’t gone through all orders as I did before

33. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Verification: Confirm OrderCancel Chest CT scan Click here

34. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Qualifier: Confirm OrderCancel Chest CT scan Urgency Stat Frequency Every: Hour Click here

35. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records 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 Click here

36. Schedule Appointment On In With next available result Call/see me as needed PE or Interval History Order Obtain lab results or see the patient later Patient Location SonMonTueWedThuFriSat 1234567 891011121314 15161718192021 22232425262728 DaysHoursMins OkCancel Click here Add mins to get CT scan result

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

38. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Input: Confirm OrderCancel Consult surgery Click here Once you click on “confirm order” it will follow the same way as you have already seen in other cases before. So I haven’t gone through all orders as I did before

39. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Verification: Confirm OrderCancel Consult, surgery Click here

40. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Qualifier: Confirm OrderCancel Surgery consult Urgency Stat Frequency Every: Hour Click here

41. PE or Interval History Order Obtain lab results or see the patient later Patient Location Reason: Confirm OrderCancel Aortic Dissection needs emergency surgery Click here

42. PE or Interval History Order Obtain lab results or see the patient later Patient Location Surgery Consult: Confirm OrderCancel An emergency surgery has been schedule for this patient. If you think any additional tests or therapies are needed, order them Click here

43. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order sheet Progress note Vital signs Lab report Imaging Other tests Tx Records Order Route/Urgency Frequency Time Order Time Report For this case, an emergency surgery has been schedule so Now it is time to ask the patient how he is feeling. Click here

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

45. Confirm H&P Choices: OkCancel PE or Interval History Order Obtain lab results or see the patient later Patient Location Interval Follow-up………………………………2 mins Total minutes: 2 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

46. Interval Follow-up: OkCancel PE or Interval History Order Obtain lab results or see the patient later Patient Location No change in patient’s condition

47. Case-end Instruction: OK PE or Interval History Order Obtain lab results or see the patient later Patient Location This case will end in 5 mins “Real Time” On the next screen finalize the order (adding / deleting) according to patient’s current condition then confirm your order and enter your diagnosis Click here

48. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Review : Write new OrderExit Case You will see all orders here. You can delete orders (just by click on it. It will ask you stop or cancel) which you don’t want to continue or you can write new orders by clicking on “Write new Orders” Click here Review Chart

49. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Input: Confirm OrderCancel Stop smoking Safe sex Educate patient Low salt diet Click here Follow ordering process as you have already gone through before

50. PE or Interval History Order Obtain lab results or see the patient later Patient Location Order Review : Write new OrderExit Case You will see all orders here. Now you can exit the case by click on “Exit Case”. Click here Review Chart

51. PE or Interval History Order Obtain lab results or see the patient later Patient Location Enter your final diagnosis : OK Aortic Dissection Click here