Microskills Cases
15 minutes Dr. Gutwein talking about the microskills
5 minutes role play between Gutwein and one of the residents
10 minutes with residents pairing off to try it out on each other
Case #1 (Dr. Gutwein and a resident)
Intern: I just saw Mr. Smith. He told the nurse he felt chest pain and the nurse asked me to come see him
immediately. When I got there he told me the pain had started 10 minutes ago and feels “heavy.” When I
asked him how bad it was he said it was 8 out of 10. He also said he is finding it difficult to breathe now. I
gave him a sublingual nitroglycerin and came to find you.
Resident (wrong way): You did what! You idiot! Did you even think of doing an EKG or getting a pulse ox?
Lets go there now before you kill him.
Resident (right way): What do you think is going on (skill 1)?
Intern: I think he is having an MI.
Resident: Why do you think he is having an MI (skill 2)?
Intern: Because I have always read that a patient having an MI has chest pain and can describe it as feeling
heavy and being short of breathe.
Resident: That is true, an MI can present like that, and sublingual nitroglycerin is a good medication to give
to help someone having an MI (skill 4). If you thought it was an MI you should not have just left the patient
to find me after the sublingual nitroglycerin (skill 5). All patients that are possibly having an MI should have
an immediate EKG and blood drawn to check for enzymes as well (skill 3). What else can present like this
patient did (skill 1)?
Intern: A PE?
Resident: Yes that is an excellent addition to your differential. Why do you think it could be a PE (skill 2)?
Intern: He has been hospitalized and immobile for a few days. Also his chest pain and shortness of breathe
can be from a PE.
Resident: Good. What tests do you think we should do to work up a PE (skill 1)?
Intern: I could have done a pulse ox, I guess. A d-dimer can help rule out a PE, I think.
Resident: A pulse ox would have been a good start but an ABG can be even more useful so that you can
calculate an A-a gradient. D-dimer is only really good at ruling out in a low risk patient in an ambulatory
setting not our inpatient. A CT with PE protocol would also be an excellent next step if our suspicion is high
enough. Let’s go see him together and get the EKG, pulse ox, cardiac enzymes and ABG.
Case #2 (2 resident pairs)
Intern: I just saw Mr. Smith. His blood pressure is dropping and the nurse asked me to see him quickly. The
nurse got a BP of 100/60 and a minute later 90/50. When I go there his vitals were BP 80/40 P102 R22
T99.8. I asked him how he felt and he said he was “dizzy.” I think we gave him too much of his blood
pressure medication Metoprolol, which is a beta blocker so I gave him a beta-agonist by nebulizer. Ok?
Case #3 (2 resident pairs)
Intern: I just saw Mr. Smith. He told the nurse he had “belly pain” and she asked me to see him. When I got
there he told me the pain was there for the last 4 days while he has been in the hospital for a bleeding ulcer,
but now had become much worse for the last 30 minutes. He barely moves in bed and was pretty tender
when I touched his abdomen. He doesn’t really have bowel sounds right now but he is barely eating anyway.
I ordered an abdominal x-ray and changed his PO Protonix to IV. Ok?