For Examiner Only
Case
Author;Christine Sullivan, MD
Reviewer; Jumana Nagarwala, MD
Approved; 10/11/05
ORAL CASE SUMMARY
CONTENT AREA
Uro/Renal
SYNOPSIS OF CASE
This case involves a 62-year-old man who presents with confusion. Wife states that he seems
disoriented at times and has been in bed for 3 days. Patient complains of weakness and nausea.
The candidate must identify that the patient has altered level of consiousness, acute renal failure
with increased anion gap metabolic acidosis, and hyperkalemia. The candidate must initiate
treatment for hyperkalemia to prevent deterioration of cardiac rhythm, call nephrologist to consider
immediate dialysis.
SYNOPSIS OF HISTORY
The patient developed a gradual onset of weakness, decreased appetite, nausea with occassional
vomiting over the past 3 days. He has been lethargic and unable to get out of bed without
assistance from wife. Wife states in the last 24 hours he seems confused.
SYNOPSIS OF PHYSICAL
Exam reveals blood pressure of 110/60, heart rate 80, respiratory rate 20, 98.8 F. Patient has no
significant physical findings other than on neurologic examination he is oriented to person only, no
focal findings.
CRITICAL ACTIONS
1. Obtain history from family member (wife)
2. Perform initial bedside evaluation/treatment including O2 sat, monitor, IV, accucheck
3. Identify acute renal failure as cause of altered mental status
4. Identify hyperkalemia, request ECG, and identify peaked T waves
5. Initiate treatment of hyperkalemia
6. Obtain emergent nephrology consult for possible dialysis
7.
SCORING GUIDELINES
(Critical Action No.)
Score down if candidate delays in obtaining history from wife as patient unable to give clear
history (#1)
Score down if candidate fails to perform bedside evaluation/treatment of altered mental status
including O2 sat, oxygen, monitor, IV, accucheck (#2)
Score down if candidates fails to recognize acute renal failure as etiology of altered mental status
(#3)
Score down if candidate fails to recognize hyperkalemia as emergent issue, does not order ECG
in timely fashion, and fails to recognize ECG changes (#4)
Score down if candidate fails to initiate treatment for hyperkalemia: calcium, sodium bicarbonate,
D50W, possible kayexalate, lasix, albuterol nebulized treatment (#5)
Score down if candidate fails to request emergent nephrology consult (#6)
FOR EXAMINER ONLY
For Examiner Only
PLAY OF CASE GUIDELINES
(Critical Action No.)
1. Candidate must realize that the patient cannot provide an accurate history and seek out family
member (wife) for more information. If this is not done, the full history should not be offered and
delay in diagnosis may occur.
2. Bedside evaluation/treatment for altered mental status should occur including O2 sat, oxygen,
cardiac monitor, IV, accucheck. If these are not done in a timely manner, the patient should
become more confused, the heart rate should slow, and the patient will have development of
shock related to deterioration in heart rhythm secondary to hyperkalemia.
3. Upon review of laboratory data, acute renal failure should be identified as the cause of altered
mental status. If not discussed as etiology by candidate, a further delay in diagnosis by additional
testing may occur. The patient's condition should worsen with decreased level of consciousness,
development of hemodynamic compromise.
4. Failure to react to hyperkalemia and order ECG in timely fashion will result in worsening of
heart rhythm and deterioration of vital signs, ultimately resulting in cardiac arrest.
5. Failure to initiate treatment of hyperkalemia to insure cardiac stability will result in worsening of
heart rhythm and deterioration of vital signs, ultimately resulting in cardiac arrest.
6. Failure to request emergent consultation with nephrology for possible dialysis will result in
worsening of heart rhythm and deterioration of vital signs, ultimately resulting in cardiac arrest.
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
Obtain history from family member (wife)
This critical action is met by candidate asking if family present to provide further information.
Cueing Guideline: Nurse can ask, "Would it be alright if the wife came back, she is concerned her
husband doesn't know what is going on."
2. Perform initial bedside evaluation/treatment
including O2 sat, monitor, IV, accucheck
This critical action is met by requesting O2 sat, ordering oxygen, ordering monitor and IV,
requesting accucheck be performed.
Cueing Guideline: Nurse can state, "Is the patient diabetic? His pulse seems a bit weak."
3. Identify acute renal failure as cause of altered
mental status
This critical action is met by identifying acute renal failure as cause of altered mental status.
Cueing Guideline: Wife can ask, "Doctor, what do you think is wrong with my husband?"
4. Identify hyperkalemia, request ECG, and identify
peaked T waves
This critical action is met by candidate commenting on hyperkalemia and requesting ECG
Cueing Guideline: Nurse can state, "His pulse seems to not be as strong."
5.
Initiate treatment of hyperkalemia
This critical action is met by candidate ordering medications including: calcium, sodium
bicarbonate, D50W, possible kayexalate, lasix, albuterol.
Cueing Guideline: Nurse can state, "What's going on with his monitor?" Examiner can ask, "Why
are you giving those medications, what is the mechanism?"
6. Obtain emergent nephrology consult for possible
dialysis
This critical action is met by candidate requesting nephrology consult
Cueing Guideline: Wife can ask, "Does he need a specialist?"
7.
This critical action is met by
Cueing Guideline:
For Examiner Only
History Data Panel
Age: 62
Sex: male
Name: John Smith
Method of Transportation: ambulance
Person giving information: patient
Presenting complaint: weakness
Onset and Description of Complaint: Patient states his wife insisted on calling ambulance
because he complained of being tired with nausea and some vomiting. He states, "I'm not really
sure why I'm here."
Past Medical History
Allergies: none
Medical: HTN
Surgical: remote left knee surgery
Last Meal: "a couple of days ago"
Habits
Smoking: no
Drugs: no
Alcohol: no
Family Medical History
Father: HTN
Mother: breast cancer
Siblings: HTN
Social History
Married: yes
Children: 2 grown, live out of state
Employed: businessman
Education: college degree
PMD:
For Examiner Only
Physical Data Panel
General Appearance: well-developed, well-nourished man, somewhat lethargic
Vital Signs:
BP
:
P
:
R
:
T
:
O2Sat
:
Glucose :
110/60
80
20
98.8 F
not initially reported
not initially reported
Neurological: no focal findings
Mental Status: slightly lethargic, oriented to person only, when told where he is asks, "Why am I
at the hospital?"
Head: atraumatic
Eyes: PERRLA, discs sharp, EOMI
Ears: clear
Mouth: slightly dry mucous membranes
Neck: supple, no JVD, no bruit
Skin: dry, warm, no rash
Chest: CTA
Heart: normal
Abdomen: normal
Extremities: normal
Rectal: good tone, stool negative for occult blood
Pelvic: N/A
Back: normal
Other exam findings: none
For Examiner Only
Lab Data Panel
Stimulus #2 – CBC
WBC
8,500 /mm3
Hgb
10.3 g/dl
Hct
30.9 g/dl
Platelets
240,000/mm3
Differential
Segs
60%
Lymphs
28%
Mono
10%
Eos
2%
Stimulus #5 – ABG
pO2 82, pH 7.23, pCO2 33
Stimulus #6 – Powerpoint attachment slide 2
Stimulus #7 – Powerpoint attachment slide 3
Stimulus #8 – Powerpoint attachment slide 4
Stimulus #9 –
Stimulus #10 –
Stimulus #3 – Chemistry
Na+
130 mEq/L
K+
7.4 mEq/L
HCO312 mEq/L
Cl98 mEq/L
Glucose
160 mg/dL
BUN
41 mg/dL
Creatinine
7.2 mg/dL
Stimulus #4 – Urinalysis
Color
Yellow
Sp Gravity
1. 018
Glucose
Negative
Protein
1 plus
Ketone
Negative
Leuk. Est.
Negative
Nitrite
Negative
WBC
0-2 /HPF
RBC
3-5 /HPF
Stimulus #11 –
VERBAL REPORTS
CT head negative
Cardiac enzymes negative
For Examiner Only
Stimulus Inventory
Stimulus #1 – Emergency Admitting Form
Stimulus #2 – CBC
Stimulus #3 – Chemistry
Stimulus #4 – Urinalysis
Stimulus #5 – ABG
Stimulus #6 – ECG
Stimulus #7 – Rhythm strip 1
Stimulus #8 – Rhythm strip 2
Stimulus #9 –
Stimulus #10 –
Stimulus #11 –
FOR EXAMINER ONLY
Mock Oral Feedback Form
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
1. Obtain history from family member (wife)
 and omissions
2. Perform initial bedside evaluation/treatment including
O2 sat, monitor, IV, accucheck
3. Identify acute renal failure as cause of altered mental
status
4. Identify hyperkalemia, request ECG, and identify
peaked T waves
5. Initiate treatment of hyperkalemia

6. Obtain emergent nephrology consult for possible
dialysis
7.





Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
: John Smith
Age
: 62
Sex
: male
Method of Transportation : ambulance
Person giving information : patient
Presenting complaint
: weakness
Background:
Patient developed a gradual onset of weakness, decreased appetite, nausea with
occassional vomiting over the past 3 days. Wife called paramedics this morning to
transport patient for evaluation.
Vital Signs
BP
110/60
P
80
R
20
98.8 F
Stimulus #2 – CBC
WBC
Hgb
Hct
Platelets
Differential
Segs
Lymphs
Mono
Eos
8,500 /mm3
10.3 g/dl
30.9 g/dl
240,000/mm3
60%
28%
10%
2%
Stimulus #3 – Chemistry
Na+
K+
HCO3ClGlucose
BUN
Creatinine
130
7.4
12
98
160
41
7.2
mEq/L
mEq/L
mEq/L
mEq/L
mg/dL
mg/dL
mg/dL
Stimulus #4 – Urinalysis
Color
Sp Gravity
Glucose
Protein
Ketone
Leuk. Est.
Nitrite
WBC
RBC
Yellow
1. 018
Negative
1 plus
Negative
Negative
Negative
0-2 /HPF
3-5 /HPF
Stimulus #5 – ABG
pO2 82, pH 7.23, pCO2 33
Stimulus #6 ECG
Stimulus #7 – Rhythm strip 1
Stimulus #8 – Rhythm strip 2