CrackTheNac 8 Case for the NAC OSCE

8 CASES FOR THE NAC OSCE www.crackthenac.com

8 CASES FOR THE NAC OSCE

Thanks for downloading our free ebook to help you prepare for the NAC OSCE. We definitely appreciate how stressful preparing for this exam can be and how important a top score is to your residency applications and eventual practice in Canada. We also understand how there is virtually 0 information on this exam out there and how secretive the MCC is with any of their exams. We’ve assembled 8 cases to help get you started and begin your prep for the exam. There are no right answers to these cases; they are simply opening paragraphs, similar to ones you may see in the NAC OSCE. These should be used as a guide to help you think critically, act, and work your way towards total preparation. We suggest you read the opening statement and then explore the checklists. Consider what you would ask, what you would do, and how you would proceed with your exam. Think about common issues, and the most likely answers to the examiner questions. As well we’ve added some study tips and suggestions at the end of each case. One final piece of advice: practice, practice, practice, grab a friend, a sibling, a colleague and rehearse every physical exam, rehearse every algorithm for questions, and know your public health and medicolegal guidelines inside and out.

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8 CASES FOR THE NAC OSCE

Case 1: Directions: Rebecca Johnston, A 27-year old woman comes into the office complaining of chest pain. Obtain a complete history of this complaint. Do not perform a physical exam.    

Introduces self appropriately Washes hands Clarifies reason for visit Obtains history of chest pain o Onset o Location o Precipitating factors o Alleviating factors o Associated symptoms o Quality o Radiation o Severity o Timing/duration  Identifies risk factors for heart disease o Past medical history o Family history of heart disease or risk factors o Smoking history o Illicit Drug use (especially cocaine) o Hypertension o Lipids/cholesterol o Recent stressors o Exercise tolerance  Focused review of systems o Heartburn/GERD symptoms o Pain with movement/palpation o Medications o Allergies o Summarizes history o Checks for any other concerns or missed information Possible examiner questions:  What tests would you like to order?  What is your most likely diagnosis? Give up to 2 differential diagnoses  Please provide the patient with advice on managing “panic attacks”

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8 CASES FOR THE NAC OSCE

Tips 1. 2. 3. 4.

Always rule out the most serious causes first. Use clear open ended questions. Write down the most common Dx on your notepad as you read the case. Think about age appropriate diagnoses – is it likely that a 27 year old woman is having an MI? Or is it more likely anxiety? How will this influence your choice of tests? What tests would you order if she were 67? Would these tests change if she had a history of trauma? 5. Prepare to provide counselling to the patient. They are testing to see how you can not only diagnose, but communicate common and important health issues in a real setting.

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8 CASES FOR THE NAC OSCE

Case 2 Directions: Mr. Lee Vasan a 57 year old male reports to outpatients with a 48 hour history of abdominal discomfort. He reports he has not passed gas or stool for at least a day. He has experienced 1 episode of vomiting. Please perform a focused physical exam.        

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Introduces self appropriately Washes hands Clarifies reason for visit Obtains consent for personal exposure Exposes abdomen Drapes appropriately Requests Vital signs Inspection o Looks for peristaltic waves o Looks for distension o Looks for bruising, scars, mass Auscultation o Listens for bowel sounds o Listens for bruits Percussion o Percusses abdomen o Percusses liver o Percusses spleen o Comments on tenderness Palpation o Light palpation o Deep palpation o Requests Digital rectal exam o Requests external genital exam o Palpates for  Appendicitis  Palpates for AAA  Hepatomegaly Makes appropriate closing remarks Examiner question: o What tests would you like to perform o Based on attached image (Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 17788)

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8 CASES FOR THE NAC OSCE

 Provide a diagnosis and up to 2 differential diagnoses.  What is your next course of action? TIPS 1. Be prepared to see simple X-rays. It is important to be familiar with classic head, cervical, spinal, lung, abdomen, and limb fractures. Images will be simple and straight forward and should be easy to spot by any future resident. 2. Know all signs and symptoms for classic and common abdominal/hepatic/renal presentations. The exam will not feature anything weird and wonderful, but you will be penalized for missing murphy’s sign, jaundice, etc. 3. Comment on anything and everything you see. 4. Comment on what you are looking for, what you see, and what that might mean. They want to understand your thinking process. Are you fit for practice in Canada?

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8 CASES FOR THE NAC OSCE

Case 3: A 16 year old boy with a history of asthma presents to his family doctor’s office complaining of recurrent shortness of breath since moving in with his father. (His parents are separated). Obtain a detailed history and explore possible causes.    

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Introduces self to patient Washes Hands Establishes reason for visit History o Character o Onset o Duration o Frequency o What makes it worse? What makes it better? o Current medications Asks about o Smoking o Pain o Exposure to chemicals/irritants o Exposure to pets/birds o Nocturnal cough o Exercise Tolerance o Shortness of breath o Snoring o Carpeting o Fireplace Previous Medical History Allergies Social History o Alcohol o Tobacco o Marijuana o Illicit drugs Family History

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8 CASES FOR THE NAC OSCE

Examiner Questions: Please explain to the patient how to use an aerochamber inhaler? What tests would you like to perform? What is the initial treatment for asthma? What other medication can be added to this treatment if symptoms persist? Please explain to the patient common asthma triggers. TIPS 1. It is important to be well versed on common patient education issues including but not limited to: using an aerochamber, checking blood sugar, injecting insulin, various forms of contraception, etc. Don’t be surprised if you are asked to counsel a patient on these topics. 2. Know a variety of go to tests for common presentations – asthma, chest pain, abdominal pain, lower back pain, when to order a pregnancy test, urine dip, swab, etc. You may be asked to refer a patient or to request testing- verbalize all of these during your case. 3. Be aware of basic algorithms for treatment of things like asthma, diabetes, hypertension, it is unlikely that you will be asked to choose a specific dose or a frequency, but knowing that X is first line, Y is added to first line, and Z is third in line for treatment is important for both the NAC OSCE and clinical practice. 4. Practice counselling individuals on a variety of lifestyle treatments – diet, exercise, prevention, etc. You will be asked to do this during the exam.

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8 CASES FOR THE NAC OSCE

Case 4: A 21 Month old female is brought to the clinic by her parents as they are complaining that she has been having loose stools. Please obtain a focused history from her mother while the nurse evaluates the child’s vital signs.     

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Introduces self to parents Establishes reason for visit Washes hands Relevant history Asks about presence of o Blood o Oily o Pus o Mucus o Colour/Consistency o Fowl smelling o Frequency o Constipation Duration Onset Associated Symptoms ex: vomiting Aggravating/Mitigating factors Fever Diet Weight loss/gain Travel Vaccinations Previous Medical History Family Medical History Medications Allergies Prenatal Care Postnatal Care Duration and complications related to pregnancy

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8 CASES FOR THE NAC OSCE

Examiner questions: Please list 1 primary diagnosis and 2 secondary diagnoses. How would you diagnose Cystic fibrosis in this patient? How would you assess this child for dehydration? Assuming all of her vaccinations are up to date, what vaccines should she receive at her next visit? When would you schedule this visit? TIPS 1. While it is very unlikely you will see a paediatric patient in the NAC OSCE as they are difficult to standardize for a national exam, it is likely that you will see the parent/caretaker of a child and be asked to obtain a history. 2. Being able to take a paediatric history for head to toe is vital to obtain a top mark in this exam. What illnesses are specific to children? What allergies are most common in children? What social issues are involved? 3. Know the social and legal issues for paediatric patients inside and out. 4. What is the age of consent in Canada? How does this affect your steps in management? Consider what happens if a pre-teen/teen requests to not involve their parents? 5. What are the current guidelines for vaccines in Canada? Ages? Schedule? What happens with a missed vaccine? What happens if a child has a fever or is unwell at a scheduled vaccination appointment?

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8 CASES FOR THE NAC OSCE

Case 5 Jennifer Stevens is a 17 year old female that presents to the clinic for personal reasons. Please determine the reason for her visit and conduct a focused history.    

Introduces self to patient Establishes reason for visit – foul smelling vaginal discharge Washes hands Enquires about o Onset o Duration o Character o Sexual history  Rape? Abuse? o Sexual orientation o Contraception and barrier protection o Obstetric history o Menstrual history o Abnormal bleeding o Urinary symptoms  Previous medical history o Previous STI/Pregnancy/ectopic o Surgery  Medications o Oral ABX o Oral Contraception  Social History o Smoking o Alcohol o Drugs o Work life o School life o Who is she at home with?

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8 CASES FOR THE NAC OSCE

Examiner questions: Please provide 3 possible diagnoses? Please specify 3 tests you would like to perform? If a vagina swab is positive for chlamydia, what is your next course of action? Please counsel the patient on prevention of the spread of sexually transmitted infections. TIPS 1. 2. 3. 4. 5. 6. 7. 8.

Social cases involving youth/young adults are common in nearly all 4th year OSCEs. What diseases must be reported to public health? Does the partner have to be notified? What are the laws surrounding HIV? What if the individual reports sexual abuse? Rape? Sex with a minor/adult? What is the age of consent in Canada? What if they ask you to not inform their parents? What are the laws surrounding abortion?

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8 CASES FOR THE NAC OSCE

Case 6 Mr. Samuel Jones is a 63 year old man with a 20 year history of diabetes he presents to your clinic today for his annual diabetic check-up. Please perform a physical exam. Do not perform funduscopic exam.    

Introduces self to patient Washes hands Explains physical exam Examines Foot o Comments on  Colour  Skin  Ulcers  Swelling  Calluses  Deformities o Palpation  Temperature  Capillary refill  Pulses  Dorsalis pedis  Posterior tibial o Sensation  Correctly uses monofilament  Asks patient to close eyes  Hallux  Metatarsal heads  Places tuning fork on distal phalanx of great toe o Completes exam on both feet o Examines proprioception of great toe o Ankle jerk reflex  Closes interview

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8 CASES FOR THE NAC OSCE

Examiner questions Please advise the patient on proper foot care. List 3 complications of diabetes. What 3 tests would you like to perform to conclude this annual checkup? Tips 1. Be prepared for classic presentations in classic patients. These cases are developed by physicians for future physicians. You will not be asked to examine something weird and unique. Cases will present like a normal day in a family practice so you should be able to examine and diagnose classic presentations. 2. There are no tricks, if the instructions ask you to perform a foot exam, that’s all you are required to do. There will be no secret malignancy lurking in the case. No secret social issues hidden in a foot exam. 3. Re-read the instructions if you get lost. They are generally very clear and concise. They will instruct you what to perform, and what not to perform. 4. “I’m looking for, I’m palpating for, I’m listening for…” these phrases are your friends for physical exam stations, talk, talk, and talk more so you leave no doubt in the examiner’s mind that you know your stuff and you know what you are doing and why.

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8 CASES FOR THE NAC OSCE

Case 7 Mrs. Abigail Johnson is brought into to your clinic by her 30 year old son for a renewal of her narcotics prescription. Please explore the reasons for her visit and address any concerns she may have. Do not perform a physical exam.     

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Introduces self to patient Washes hands Establishes reason for visit Establishes reason for narcotics prescription Assesses Pain o Location o Onset o Duration o Intensity o Provocative/Palliative factors Assesses narcotic use o How often does she take the pills o Does she take any other pain medication o Sleep quality o Does anyone else have access to her medication o When was her last renewal o How many pills does she take at a time/per day Establishes patient has run out of pills early Establishes that she feels pressured to get more pills Establishes that her pills are going missing Establishes that she may feel threatened if she does not get more pills

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8 CASES FOR THE NAC OSCE

Examiner questions: What is your diagnosis? What is your next course of action? If this patient’s son is diverting her narcotics how would you manage her pain? TIPS 1. The NAC will assess more than your clinical knowledge it will test you on social and legal issues. 2. Be prepared for a variety of social and legal situations. What would you do if you suspected elder abuse? What is the next course of action if her medication is being misused or sold? 3. Does she really need this level of treatment? 4. This is a common clinical scenario and it is important to know how to effectively manage these tough presentations.

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8 CASES FOR THE NAC OSCE

Case 8 Mrs. Gladys Mortimer, a 72 year old female presents to your clinic with recurrent “accidents” resulting in her needing to change her underwear and pants more than once a day. As a result she is now reluctant to leave the house. Please explore the reason for her visit and conduct a focused history.    

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Introduces self to patient Washes hands Establishes reason for visit History of Present Complaint o Character o Onset o Intensity o Duration o Aggravating/Mitigating factors Asks about o Pain o Fullness o Difficulty voiding o Blood in urine o Fever/chills o Weight loss o Kidney stones Previous Medical History o Malignancy o Obstetric History o Surgery o Renal history o Bladder History o Diabetes MEDS o Anticholinergic o Diuretics Social History o Smoking o Alcohol o Drugs o Sex history o Activities of daily living o Support at home

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8 CASES FOR THE NAC OSCE

Examiner questions: What is your primary diagnosis, list 2 alternative diagnoses? What tests would you order for this patient?

TIPS 1. Paediatrics, geriatrics, and social issues are often tested on this exam. Be well versed in common presentations and course of action. 2. Demonstrate compassion and understanding, this will count for marks on the exam. 3. Use clear concise language; do not use jargon or difficult terms. This exam is equally as much a test of your communication skills as it is of your knowledge. You can make up for shortcomings of knowledge with communication, but you cannot make up for poor communication with knowing everything.

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