{ "orders": [], "cases": [ { "externalId": "ccs-gastro-duodenal-ulcer-office-001", "isPublished": true, "title": "Office Visit — 44-year-old man", "system": "Gastrointestinal System", "presentingLocation": "office", "realTimeMinutes": 10, "difficulty": 1, "tags": ["history taking", "dyspepsia", "duodenal ulcer", "Helicobacter pylori"], "experienceMode": "graphical_interview", "graphicalPresentation": { "sceneKey": "doctor_office", "patientAssetKey": "patient_44_white_male", "interviewRevision": 2 }, "initialChart": { "patientSummary": "44-year-old man attending an office visit", "reasonForEncounter": "The reason for the visit has not yet been elicited.", "appearance": "He is seated comfortably, attentive, and in no acute distress.", "history": "Several weeks of intermittent lightheadedness and fatigue accompany three weeks of sleep-disrupting, burning epigastric discomfort rated 4/10. Food and antacids provide temporary relief. He reports belching, fullness, and occasional black stool without frank blood. He has hyperlipidemia and no recent sick contacts, travel, or antibiotic use.", "historySections": [ { "code": "chief_concern", "title": "Chief concern", "text": "Intermittent lightheadedness and fatigue for several weeks." }, { "code": "abdominal_symptoms", "title": "Abdominal symptoms", "text": "Burning, non-radiating epigastric discomfort has been present for three weeks, is rated 4/10, is unaffected by position or movement, and improves temporarily after food or antacids." }, { "code": "associated_symptoms", "title": "Associated symptoms", "text": "Belching, fullness, sleep disruption, and occasional black stool without frank blood." }, { "code": "past_medical_history", "title": "Past medical history", "text": "Hyperlipidemia" }, { "code": "exposure_history", "title": "Exposure history", "text": "No recent sick contacts, travel, or antibiotic use." } ], "vitals": { "temperature": "36.8 C (98.2 F)", "bloodPressure": "122/76 mm Hg", "pulse": "76/min", "respirations": "14/min", "oxygenSaturation": "99% on room air" }, "simulatedStartUtc": "2026-08-05T09:00:00Z", "initialOrderCodes": [] }, "initialInterview": { "openingPatientText": "Good morning, doctor.", "finishChoiceText": "Thank you. I have enough history for now.", "closingPatientText": "Thank you, doctor. I hope we can figure out what has been going on.", "topics": [ { "id": "chief_concern", "clinicianText": "Good morning. What brings you in today?", "patientText": "For the past few weeks, I have felt worn out, and every so often I get lightheaded—especially when I stand up quickly.", "required": false }, { "id": "dizziness_character", "clinicianText": "Tell me more about the dizziness. Does the room spin, and have you fainted?", "patientText": "The room does not spin. It is more like I might black out for a second when I get up, but I have never actually fainted. I have had no weakness, numbness, trouble speaking, chest pain, or racing heartbeat.", "required": true, "prerequisiteTopicIds": ["chief_concern"] }, { "id": "fatigue_course", "clinicianText": "How has the fatigue affected you, and how have you been sleeping and eating?", "patientText": "My energy is down by the afternoon. My appetite is about the same, but lately a burning discomfort high in my abdomen sometimes wakes me at night.", "required": true, "prerequisiteTopicIds": ["chief_concern"] }, { "id": "abdominal_character", "clinicianText": "Tell me more about the abdominal discomfort—where is it, what does it feel like, and how long has it been happening?", "patientText": "It started about three weeks ago. It is a burning pain in the upper middle part of my abdomen. It does not spread anywhere, I would rate it about a four out of ten, and changing position or moving does not make it better or worse.", "required": true, "prerequisiteTopicIds": ["fatigue_course"] }, { "id": "relieving_factors", "clinicianText": "Does anything make the discomfort better or worse?", "patientText": "Eating usually settles it for a while, and antacids help too. Position and movement do not seem to change it.", "required": true, "prerequisiteTopicIds": ["abdominal_character"] }, { "id": "associated_gi", "clinicianText": "Have you noticed belching, fullness, vomiting, or any blood or change in the color of your stool?", "patientText": "I have been belching more and sometimes feel unusually full. I have not vomited or seen red blood, but my stool has looked black on occasion.", "required": true, "prerequisiteTopicIds": ["abdominal_character"] }, { "id": "exposure_history", "clinicianText": "Have you had any sick contacts, recent travel, or antibiotic use?", "patientText": "No. I have not been around anyone sick, traveled recently, or taken antibiotics.", "required": true, "prerequisiteTopicIds": ["abdominal_character"] }, { "id": "past_medical_history", "clinicianText": "Do you have any past medical conditions?", "patientText": "A few years ago, my doctor told me my cholesterol was high. Other than that, I have not been diagnosed with any major medical problems.", "required": false, "prerequisiteTopicIds": ["chief_concern"] } ], "debrief": { "likelyDiagnosis": "Peptic ulcer disease with possible intermittent upper gastrointestinal bleeding", "summary": "The history identifies orthostatic lightheadedness and fatigue accompanying burning epigastric pain relieved by food and antacids, with occasional black stool concerning for intermittent upper gastrointestinal bleeding.", "teachingPoints": [ "Clarify whether dizziness is vertigo, presyncope, or disequilibrium and screen for neurologic and cardiac warning symptoms.", "Characterize epigastric pain by timing, quality, severity, radiation, triggers, and relieving factors.", "Ask specifically about melena or hematemesis because occult or intermittent bleeding can present with fatigue and lightheadedness." ] } }, "allowedLocations": ["office"], "exams": [], "orderResponses": [], "events": [], "scoringCriteria": [ { "id": "elicit_chief_concern", "title": "Elicit the chief concern", "actionType": "dialogue_choice", "targetCode": "chief_concern", "points": 10, "rationale": "An open-ended opening allows the patient to identify lightheadedness and fatigue in his own words." }, { "id": "characterize_dizziness", "title": "Characterize the dizziness", "actionType": "dialogue_choice", "targetCode": "dizziness_character", "points": 15, "rationale": "Distinguishing presyncope from vertigo and screening for neurologic and cardiac warning symptoms focuses the differential." }, { "id": "explore_fatigue", "title": "Explore fatigue, sleep, and intake", "actionType": "dialogue_choice", "targetCode": "fatigue_course", "points": 10, "rationale": "The course and associated symptoms help characterize the nonspecific fatigue." }, { "id": "characterize_abdominal_pain", "title": "Characterize the abdominal discomfort", "actionType": "dialogue_choice", "targetCode": "abdominal_character", "points": 15, "rationale": "Location, quality, duration, severity, and radiation help characterize the source of pain." }, { "id": "identify_relief", "title": "Identify relieving and aggravating factors", "actionType": "dialogue_choice", "targetCode": "relieving_factors", "points": 10, "rationale": "Temporary relief with food or antacids supports an acid-related pattern." }, { "id": "screen_gi_bleeding", "title": "Screen for gastrointestinal bleeding", "actionType": "dialogue_choice", "targetCode": "associated_gi", "points": 15, "rationale": "Occasional black stool may represent melena and requires recognition." }, { "id": "review_exposures", "title": "Review relevant exposures", "actionType": "dialogue_choice", "targetCode": "exposure_history", "points": 5, "rationale": "Recent illness, travel, and antibiotic exposure help refine the gastrointestinal differential." } ], "references": [ { "title": "Peptic Ulcer Disease", "publisher": "American College of Gastroenterology", "url": "https://gi.org/topics/peptic-ulcer-disease/", "supports": "Typical ulcer symptoms, bleeding warning symptoms, NSAID history, H. pylori evaluation, and endoscopic diagnosis", "accessedOn": "2026-08-05", "reviewer": "Question bank editorial review" }, { "title": "ACG Guideline on Treatment of Helicobacter pylori: New Recommendations", "publisher": "American College of Gastroenterology", "url": "https://gi.org/journals-publications/ebgi/schoenfeld_sep2024/", "supports": "H. pylori treatment principles and confirmation of eradication", "accessedOn": "2026-08-05", "reviewer": "Question bank editorial review" } ] } ], "validateOnly": false }