NAC OSCE - A Comprehensive Review

NAC OSCEA Comprehensive Review

First Edition

Copyright @ 2011, Canadaprep.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any

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system, without permission in writing from the publisher. Reproducing passages from this book without such

written permission is an infringement of copyright law.

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted

practices. However, the authors, editors, and publishers are not responsible for errors or omissions or for any

consequences from application of the information in this book and make no warranty, expressed or implied,

with respect to the contents of the publication. The authors, editors, and publishers have exerted every effort

to ensure that drug selection and dosage set forth in this text are in accordance with the current

recommendations and practices at the time of publication. However, in view of ongoing research, changes in

government regulations, and the constant flow of information relating to drug therapy and drug reactions,

the reader is urged to check the package insert for each drug for any change in indications and dosage and

for added warnings and precautions. This is particularly important when the recommended agent is a new or

infrequently employed drug.

This publication has not been authored, reviewed or supported by the Medical Council of Canada, nor is it

endorsed by the Medical Council as a review material for the NAC OSCE.

PREFACE

This book was written due to the lack of preparation material available for the National Assessment

Collaboration (NAC) Objective Structured Clinical Examination (OSCE). As an International Medical

Graduate (IMG) preparing for clinical and written exams in Canada, there is no comprehensive review

textbook available for the NAC OSCE. Due to the lack of resource materials, many students are forced to

study from sources that are not relevant to the NAC OSCE. This eventually hampers the candidate's score

in the examination.

This book aims to guide you through the steps of the NAC OSCE and ensures that you are well prepared

and a step ahead of the competition. A great effort has been put into collecting and organizing relevant

content for both the clinical OSCE stations and the written therapeutic exam.

Written by medical graduates who are oriented to the NAC OSCE, this comprehensive review can be used

as a framework, complementing your clinical skills and therapeutic knowledge as you prepare for the

examination.

This book is dedicated to all the IMGs preparing for the medical licensing examinations in Canada.

“And most important, have the courage to follow your heart and intuition. They somehow already know what you

truly want to become. Everything else is secondary.” - Steve Jobs

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TABLE OF CONTENTS

Introduction to NAC OSCEGeneral Information ...............................................................................................................1Registration for NAC OSCE ..................................................................................................1Fees ........................................................................................................................................1Examination station ................................................................................................................1NAC OSCE scoring ...............................................................................................................2Sample of Therapeutic written test ..........................................................................................2Sample clinical case station .....................................................................................................3

Therapeutic GuidelinesMedicine

Cardiology ..............................................................................................................................7Dermatology ........................................................................................................................11Endocrinology ......................................................................................................................14Gastroenterology ..................................................................................................................16Hematology ..........................................................................................................................19Infectious Diseases ................................................................................................................19Neurology .............................................................................................................................21Otolaryngology .....................................................................................................................23Pulmonology ........................................................................................................................24Rheumatology ......................................................................................................................26Nephrology/Urology .............................................................................................................29Emergency Medicine ............................................................................................................30Counseling (smoking/alcohol) ...............................................................................................35

Obstetrics & GynecologySexually transmitted infections ..............................................................................................38Urinary tract infection ...........................................................................................................39Vulvovaginitis .......................................................................................................................39Pelvic inflammatory disease ...................................................................................................40Dysfunctional uterine bleeding ..............................................................................................40Dysmenorrhea ......................................................................................................................40Endometriosis ......................................................................................................................40Hormone replacement therapy ..............................................................................................41Emergency contraception ......................................................................................................41Group B Streptococcus in pregnancy .....................................................................................41Pregnancy induced hypertension ...........................................................................................41Ectopic pregnancy ................................................................................................................42Hyperemesis gravidarum .......................................................................................................42Drugs contraindicated in pregnancy ......................................................................................42

PediatricsAcute bronchiolitis ................................................................................................................45Acute otitis media .................................................................................................................45Asthma .................................................................................................................................45Bacterial tracheitis ................................................................................................................45Bacterial pneumonia .............................................................................................................46Croup (Laryngotracheobronchitis) ........................................................................................48Epiglottitis ...........................................................................................................................48Streptococcal pharyngitis (Group A streptococcus) ................................................................48Whooping cough (Pertussis) .................................................................................................48Bacterial meningitis ..............................................................................................................49Febrile seizures .....................................................................................................................49Urinary tract infection ...........................................................................................................49Allergic reaction ....................................................................................................................50Anemia .................................................................................................................................50Dose of tylenol .....................................................................................................................50Immunization schedule .........................................................................................................50

TABLE OF CONTENTS

PsychiatryDelerium ..............................................................................................................................52Mania ...................................................................................................................................53Panic disorder .......................................................................................................................53Social phobia ........................................................................................................................54General anxiety disorder .......................................................................................................54Obsessive compulsive disorder ...............................................................................................55Post traumatic stress disorder ................................................................................................55Dementia .............................................................................................................................55Depression ............................................................................................................................56Psychosis ..............................................................................................................................56Mood stabilizers ...................................................................................................................57Medications causing sexual dysfunction .................................................................................58Substance abuse ....................................................................................................................59

Clinical ExaminationAbdominal ...........................................................................................................................63Cardiovascular .....................................................................................................................65Peripheral vascular ................................................................................................................67Respiratory examination ........................................................................................................69Central nervous system ........................................................................................................71Upper limb neurological .......................................................................................................73Lower limb neurological .......................................................................................................75Musculo-skeletal system : Spine/Back ...................................................................................77Hip .......................................................................................................................................79Knee .....................................................................................................................................81Foot and ankle ......................................................................................................................83Shoulder ...............................................................................................................................85Elbow ...................................................................................................................................87Hand and wrist .....................................................................................................................88Breast examination ................................................................................................................90Thyroid ................................................................................................................................91Mini Mental State Examination ............................................................................................93

Clinical casesProtocol for history taking .....................................................................................................99

MedicineAtrial fibrillation .................................................................................................................102Asthma ...............................................................................................................................103Congestive heart failure .......................................................................................................104Cerebrovascular attack .........................................................................................................105Digoxin toxicity ..................................................................................................................106Infectious mononucleosis (sore throat) .................................................................................107Impotence ...........................................................................................................................108Meningitis ..........................................................................................................................109Migraine (Headache) ..........................................................................................................110Myocardial Infarction(Chest pain) .......................................................................................111Pneumonia ..........................................................................................................................112Post exposure prophylaxis for HIV ......................................................................................113Pulmonary embolism ..........................................................................................................114Seizure disorder ...................................................................................................................115Temporal arteritis ................................................................................................................116Viral hepatitis .....................................................................................................................117

Obstetrics and GynecologyAbortion .............................................................................................................................118Antenatal visit .....................................................................................................................119Ectopic pregnancy ...............................................................................................................120

TABLE OF CONTENTS

Infertility ............................................................................................................................121OCP counseling ..................................................................................................................122Pelvic inflammatory disease .................................................................................................123Placenta previa ....................................................................................................................124Pre eclampsia ......................................................................................................................125

PediatricsFailure to thrive ...................................................................................................................126Febrile seizure .....................................................................................................................127Measles ...............................................................................................................................128Neonatal jaundice ................................................................................................................129Primary nocturnal enuresis ..................................................................................................130Pyloric stenosis ....................................................................................................................131Speech delay .......................................................................................................................132

PsychiatryAnorexia .............................................................................................................................133Bulimia ...............................................................................................................................134Delirium .............................................................................................................................135Dementia ............................................................................................................................136Depression ..........................................................................................................................137Mania .................................................................................................................................138Panic attack .........................................................................................................................139Schizophrenia .....................................................................................................................140Suicide ................................................................................................................................141

SurgeryBack Pain ............................................................................................................................142Basal cell carcinoma ............................................................................................................143Benign prostatic hyperplasia ................................................................................................144Carpal Tunnel Syndrome .....................................................................................................145Deep Vein Thrombosis ........................................................................................................146Diabetic foot .......................................................................................................................147Difficulty swallowing (Ca oesophagus ) ...............................................................................148Hematemesis ......................................................................................................................149Neck swelling ......................................................................................................................150Pain abdomen .....................................................................................................................151Peripheral vascular disease ...................................................................................................152Post operative fever .............................................................................................................153Solitary lung nodule ............................................................................................................154Thyroid mass ......................................................................................................................155Trauma ...............................................................................................................................156

CounselingBreast feeding .....................................................................................................................159Child abuse .........................................................................................................................160Domestic violence ...............................................................................................................161Hormone replacement therapy ............................................................................................161Mammogram ......................................................................................................................163Immunization .....................................................................................................................164Obesity ...............................................................................................................................165Smoking .............................................................................................................................167


Introduction to NAC OSCE | General Info 1

IntroductionIntroductionIntroductionIntroduction totototo NACNACNACNAC OSCEOSCEOSCEOSCE

General InformationGeneral InformationGeneral InformationGeneral Information

The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines the assessment of IMG medical knowledge and clinical skills throughout Canada. Many international medical graduates (IMGs) find that the path to obtaining a medical license in Canada challenging and difficult to navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and clinical skills.Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice medicine in Canada. Through such a system, an IMG’s path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced CEHPEA’s Clinical Examination 1 (CE1), which was unique to Ontario.

Registration for NAC OSCERegistration for NAC OSCERegistration for NAC OSCERegistration for NAC OSCE

Registration for the NAC OSCE in Ontario starts in November, with the deadline in January the next year. Candidates are advised to complete their registration within this time-frame. Once the deadline is over, the candidate will not be able to register for the NAC OSCE for the entire year. The exams are scheduled for March, June, August and September. Visit www.mcc.ca and www.cehpea.ca for updated information.

FeesFeesFeesFees

Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change Fee: $100 All fees are in (CAD) Canadian Dollars.

Examination station Examination station Examination station Examination station

The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes between stations.At each station, a brief written statement introduces a clinical problem and outlines the candidate’s tasks (e.g. take a history, do a physical examination, etc.). In each station, there is at least one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a patient problem. Candidates should interact with standardized patients as they would with their own patients.The physician examiner observes the patient encounter. For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations.Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html

2 NAC OSCE | A Comprehensive Review

The examination includes a separate written test of candidates’ therapeutic knowledge. This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates’ knowledge of therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion.

NAC OSCE scoring NAC OSCE scoring NAC OSCE scoring NAC OSCE scoring

The candidate’s total examination score will be determined by combining the scores on the OSCE component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes, the NAC total examination scores are reported on a scale with a distribution ranging from 0 to 100 with a fixed passing mark of 65.

Number of times candidates can take the examinationNumber of times candidates can take the examinationNumber of times candidates can take the examinationNumber of times candidates can take the examination

Starting in 2011, the NAC OSCE can be attempted once per Canadian Resident Matching Service (CaRMS) cycle. If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained. Regardless of whether you pass or fail, you can only take the examination three times. If you take the examination more than once, the most recent result will be the only valid result.

Sample of Therapeutic written testSample of Therapeutic written testSample of Therapeutic written testSample of Therapeutic written test

Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance. Her ESR (Erythrocyte sedimentation rate) is 100 and you have made the diagnosis of POLYMYALGIA RHEUMATICA (PMP).

What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of administration and duration are required.)

Answer: ________________________________________________________

Answer key the marker receives:

PREDNISONE 7.5 – 20 mg PO od for 2-4 weeks following resolution of symptoms

Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox” presents with a 2 day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles).

What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain? (Drug, dose, route of administration and duration are required.)

Answer:___________________________________________________________

Answer key the marker receives:

VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR

FAMCICLOVIR (FAMVIR ®) 500 - 750 mg PO tid X 7 days OR

ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)

Introduction to NAC OSCE | General Info 3

Sample Clinical Case StationSample Clinical Case StationSample Clinical Case StationSample Clinical Case Station

Example instruction written outside the station

David Thompson, 59 years old, presents to your office complaining of jaundice.

In the next 7 minutes, obtain a focused and relevant history.

After the 7 minutes, you will be asked to answer questions about this patient.

Example of post encounter questions

Q1. The abdominal examination of David Thompson revealed no organ enlargement, no masses and no

tenderness. What radiologic investigation would you first order to help discriminate the cause of the

jaundice?

Q2. If the investigations revealed that this patient likely had a post-hepatic obstruction, what are

the two principal diagnostic considerations?

Q3. What radiologic procedure would you consider to elucidate the level and nature of the

obstruction?


Therapeutic Guidelines


Therapeutic Guidelines | Medicine 7

Therapeutic GuidelinesTherapeutic GuidelinesTherapeutic GuidelinesTherapeutic Guidelines

MedicineMedicineMedicineMedicine

1. Cardiology1. Cardiology1. Cardiology1. Cardiology

Acute Myocardial Infarction : Immediate management in ER1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto

15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. 2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID.3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn

(If pain not relieved with 3 Sublingual Nitroglycerins)4. Oxygen by nasal cannula at 4 liters per minute5. Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times.6. Non-enteric coated Aspirin 325 mg PO.7. Cardiology Consultation

Post MI drugs

DrugsDrugsDrugsDrugs BenefitsBenefitsBenefitsBenefits Side effectsSide effectsSide effectsSide effects ContraindicationContraindicationContraindicationContraindication

ACE InhibitorsACE InhibitorsACE InhibitorsACE InhibitorsRamipril – 10mg hsLisinopril – 10 mg odEnalapril – 20mg odCaptopril - 50 mg tid

↓ mortalityPrevents ventricular remodelling↓ proteinuria

Hypotension/dizzinessHyperkalemiaAngioedemaRenal insufficiencyCough, taste changes

Bilateral renal artery stenosisHx of angioedemaPregnancy

ARBARBARBARBValsartan – 160mg bidCandesartan – 32 mg od

↓ mortality↓ proteinuria

AngioedemaCough, taste changes

Beta BlockerBeta BlockerBeta BlockerBeta BlockerMetoprolol – 100mg bidAtenolol – 100mg odCarvedilol – 25mg bidPropranolol – 60-80 tid

↓ mortality↓ sudden death, reinfarction & arrhythmias Cardioselective : preferred for mild asthma and diabetes

Decreases BP & HRDizziness, fatigueSexual dysfunctionMay mask hypoglycemiaIncrease risk of cardiogenic shock

Severe/poorly controlled asthma2nd/3rd degree heart blockHR<50, SBP<90 Cocaine use

StatinsStatinsStatinsStatinsAtorvastatin – 10mg odSimvastatin – 20-40mg od

↓ mortality in post MI patients with high cholesterol

GI upset, muscle aches, myopathy, rhabdomyo-lysis, Impotence

Active liver disease, alcoholics, pregnancy

Anti-plateletsAnti-plateletsAnti-plateletsAnti-plateletsASA – 80-162mg odClopidogrel – 75mg odWarfarin – 1-10mg od

↓ vascular events GI upset, hypersensitivityGI bleed

Recent/active bleedingGI intolerance or ASA allergy

ACUTE MI TREATMENT ACUTE MI TREATMENT ACUTE MI TREATMENT ACUTE MI TREATMENT MNEMONICMNEMONICMNEMONICMNEMONICBBBB : Beta BlockersMMMM : Morphine SulphateOOOO : OxygenNNNN : NitroglycerinAAAA : Aspirin


Atrial Fibrillation

1. To control rate:• Inj Metoprolol 5 mg bolus IV, followed by infusion at 0.05 mg/kg/min, increasing as needed

to 0.2 mg/kg/min.• Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/hr.• Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins.• Tab Amiodarone (in case of heart failure):

• Loading dose: 800 – 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid.

• Maintenance: 200 mg PO od.2. To prevent thromboembolism: Assess with CHADS 2 score

• No risk: Tab Aspirin 81-325 mg PO od.• 1 moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain

INR 2-3.• > 1 moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3.

3. To control rhythm:• Tab Flecainide 300-400 mg PO bolus dose, maintenance: 50-150 mg PO bid. (First choice)• Tab Sotalol 80-160 mg PO bid. ( Second choice)• Tab Amiodarone (in case of heart failure):

• Loading dose: 800 – 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid.

• Maintenance: 200 mg PO od.• Electrical Cardioversion: 100-360 joules.

Congestive Cardiac Failure : Immediate management in the ER

• Oxygen by nasal cannula at 4 liters per minute.• Inj Furosemide (Lasix) 10 mg IV stat.• Inj Morphine sulfate IV 2-5 mg every 5-30 min prn.• Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times.• Position of patient > 45 degrees.

Non pharmacological management of Heart Failure

• Exercise : Regular physical activity• Salt restriction : symptomatic HF – 2-3g salt/day (½ tsp/day) no added salt in diet.

HF with fluid retention : 1-2g salt/day (¼ tsp/day)• Fluid intake : 1.5/2L per day in patients with fluid retention or HF not controlled by diuretics.• Daily weight measurement.• Education.• Aggressive risk reduction (BP, glucose, lipids).• Lifestyle modifications, influenza vaccination.

CHF TREATMENT MNEMONICCHF TREATMENT MNEMONICCHF TREATMENT MNEMONICCHF TREATMENT MNEMONICLLLL : LasixMMMM : Morphine SulphateNNNN : NitroglycerinOOOO : OxygenPPPP : Positive airway pressurePPPP : Position > 45 degreesDDDD : Dopamine (indicated in cardiogenic shock and hypotension)

Clinical Examination

Clinical Examination 91

Thyroid ExaminationThyroid ExaminationThyroid ExaminationThyroid Examination

1. Steps before beginning examination

• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”

• Wash/Sanitize hands• Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed.• Look for medical equipment/therapies• Show empathy.• Verbalize the steps of the examination and your findings.

2. Inspection

• Ask for patient's vitals.

• Observe patient : Is patient anxious? Weight gain/loss? Note hoarseness of voice.

• Feel pulse – rate/rhythm/volume

• Face : Facial expression ( dull in hypothyroidism)Periorbital myxedemaLoss of 1/3rd of eyebrowsHair – texture/alopeciaExophthalmos (look from behind patient), lid lagOphthalmoplegia (ask patient to follow your finger then ask for diplopia)Chemosis (redness and watering of eyes)

• Hands : Temperature, moist palms, texture, color.Assess for fine tremors, palmar eythemaPemberton's sign - is the development of facial flushing, distended neck and head superficial

veins, inspiratory stridor and elevation of the jugular venous pressure ( JVP) upon raising of the patient's both arms above his/her head simultaneously. (Thoracic inlet obstruction – e.g. due to goitre)Carpal Tunnel Syndrome (Tinel's and Phalen's Test) – associated with hypothyroidism.Arm reflexes – brisk in hyperthyroidism.

• Neck : Stand in front of the patient, inspect for neck swellings/goitre- scars, sinuses, dilated vessels.


3. Examination of the Thyroid gland and cervical lymph nodes.

• Swallow tests – Ask patient to swallow water and observe for movement of any masses.• Tongue protrusion – Thyroglossal cyst moves on tongue protrusion.• Stand behind the patient and palpate. Assess size, texture, smoothness, margins and mobility of the

thyroid gland (including when swallowing). Note the temperature over gland and adjacent skin.• Palpate cervical lymph nodes.• Percuss over sternum – Retrosternal goitre.• Auscultate for thyroid bruit – Grave's disease.

4. Examination of legs.

• Pretibial myxoedema• Peripheral edema due to congestive cardiac failure.• Delayed relaxation of ankle reflex in hypothyroidism.

5. Thank the patient after the examination.

Clinical Cases

Clinical Cases – Protocol for history taking 99

Protocol for history takingProtocol for history takingProtocol for history takingProtocol for history taking

A candidate gets 2 minutes outside the station to read the clinical case senario on the door before entering. It is essential to get yourself organised in these 2 minutes.

• Read the question properly, understand the requirement and follow instructions (e.g. if you are asked to do a physical examination, do not start taking history. You will be losing valuable time)

• You will be given a pencil and a booklet with blank pages. It is a good practice to jot down notes. • Write the name, age, sex and chief complaint of the patient.• For history of present illness, you can use the mnemonic OCDPQRSTUV+AAA.• Past and Social History : PAM HUGS FOSS• Write down your differential diagnosis.

So your note should look something like this :

Name of the patient, age, sex and chief complaints

O - OnsetC - CourseD - DurationP - PlaceQ - QualityR - RadiationS - SeverityT - TimingU – You (associated with your daily activities)V – Deja vu (Has it happened before?)A – Aggravating factorsA – Alleviating factorsA – Associated symptoms

P – Past medical historyA - AllergiesM - MedicationH – HospitalizationsU – Urinary problemsG – GIT problemsS - SleepF – Family historyO – Obstetrical historyS – Social historyS – Sexual history

Differential diagnosis :

• Knock the door before entering, relax, take a deep breath, smile and enter the room with confidence. Hand over the stickers to the physician examiner.

• Introduce yourself to the patient : e.g. “Good morning/afternoon/evening, Mr./Miss ______, I am Dr. _____ and I'm your attending physician today.”

• “So, Mr./Miss _____, what complaint has brought you here today?”• Show empathy : “Oh! I am sorry to hear that, I shall try my best to help you.”


Tammy Robbins, a 48 years old lady presented with heart racing and chest discomfort for the past 3 days. Take a focused history and perform focused physical examination.Vitals: BP - 90/70 mm Hg, HR - 146/min, irregular, RR - 12/min, Temp - 37.5°C

Clinical Info: Ms Tammy Robbins is a known hypertensive with CAD for the past 10 years, who presented with sudden onset of palpitations and chest discomfort for the past 3 days. Her symptoms are worsening for the past 24 hours. She has dyspnea. She has dizziness for the past 12 hours. Pedal edema is 2 +. She had 2 vessel angioplasty done 5 years ago. ECG shows absent P waves with irregular narrow QRS complexes. Bilateral basal rales present on lung auscultation.Clinical Case : Atrial Fibrillation (examination on page 65)

HOPI• OCD PQRST UV + AAA• How did it start? Sudden or gradual.• Is it getting worse/better or no changes in

the symptoms?• Duration of palpitations? • Associated with chest discomfort? • Describe the type of chest discomfort?• Do you have chest pain?• Any shortness of breath?• Any dizziness/light headedness?• Any fever/cough/nausea/vomiting?• Any hemoptysis?• Any chills/night sweats?• Any malaise/fatigue/weakness?• Any swelling of feet?• Any numbness/paresthesias?• Any visual problems?• Any relieving factors?• Any aggravating factors?• Any recent trauma?• List of current medications/compliance?

Past History• Do you have any medical illnesses?• Are you allergic to any medications?• Any surgeries in the past?• Past h/o recurrent infections?

Family and Social History• Do you smoke? Duration & frequency.• Do you consume alcohol? Duration &

frequency.• Do you take any recreational drugs?• Any family history of cancers/ medical

illnesses?

Differential DiagnosisAtrial fibrillation secondary to:

1. Congestive heart failure.2. Ischemic heart disease.3. Hypertension.4. Thyroid disease.

Investigations• CBC, electrolytes, glucose.• LFT, RFT, TSH.• CK, LDH, Cardiac enzymes.• 12 lead ECG.• Echocardiogram.• Chest X ray.

Management• Treat the primary cause.• Admit in cardiac care unit.• Rate control by beta blockers, calcium

channel blockers or digoxin.• Anticoagulation with heparin, then warfarin.• Rhythm control by electro or medical

cardioversion.• Assess Stroke risk by using CHADS2 score.

Clinical Cases - Counseling 161

Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her arms. Take history and address her concerns.

Counseling Case : Domestic violence

HOPI• How did the injury occur?• When did the injury occur?• Location of injury/injuries?• Circumstances in which the injury occurred?• Describe violent episode, what triggered it?• Were objects used as weapons? • Was the boyfriend remorseful afterward? • History of previous episodes of violence or

loss of temper by boyfriend?• What was the patient's response? • Has patient been in an abusive relationship

before? • Is the boyfriend controlling?• Does he restrict her activities? • Question her excessively after she has been

out?• Engages in verbal abuse or threats? • Is the violence increasing in severity? • Are there children in the house?

• Who are the biological parents of the children?

• Do the children witness physical abuse?• Ask about violence to the children, sexual

abuse?• Is the boyfriend willing to seek help?• Any stressors at home/work?

Family and Social History• Do you smoke? Amount/frequency.• Do you consume alcohol?

Amount/frequency.• Do you use recreational drugs? TRAPPED.• Does the partner abuse alcohol or other

drugs? • Economic situation?• Any family history of physical abuse?

Counseling for domestic violence• Explain that the boyfriend hitting the patient is a criminal assault and an example of domestic

violence. • Domestic violence tends to increase over time unless the victim leaves, or the abuser and couple seek

therapy. • Very often, women don't leave their abusive partner until they are seriously hurt. • Domestic violence between adult partners tends to be reflected in future behavior of children who

are exposed to it and there is a risk of violence to the children. • Child abuse is a criminal act and if suspected, is reportable to police by law. • Spousal abuse is also a criminal act but is not reportable by law. • Recommend that the patient not return to the abuser if there is risk to her safety (e.g. not the first

assault, abuser not remorseful). • If the patient does return, an exit plan should be developed to ensure patient safety. • Document all evidence of abuse (pictures, sketches) and related visits; quote patient directly in chart.• Alternatively, the patient can contact the police to obtain a restraining order on the abuser. • Develop a plan with the patient to seek alternate living arrangements (women's shelter).• Enlist the help of patient's support structure (friends, other family members).• Contact the police (patient should be informed that, if contacted, the police will lay charges whether

the patient wants to or not). • Counsel patient on how to enter into a controlled, safe environment & contact with the abuser to

discuss possible therapy for anger management and controlling behaviors.• Social worker referral and provide info about community resources.• Arrange follow up.

Alphabetical Index

Abortion - clinical case........................................118Acetaminophen ....................................................30Acne.....................................................................11Acute Bronchiolitis...............................................45Acute Cholecystitis...............................................19acute confusional state...........................................52Acute Gastroenteritis............................................16Acute Myocardial Infarction....................................7Acute Otitis Media ..............................................45Acute Pancreatitis..................................................17Acute Pharyngitis..................................................23Acute Pyelonephritis.............................................30Acute Sinusitis......................................................23Alcohol.................................................................35Alcohol withdrawal..........................................30, 59Allen Test..............................................................68Allergic reaction....................................................50Allergic Reaction...................................................30Anaphylaxis...........................................................30Anemia............................................................19, 50Ankle Anterior Drawer Test .................................84Anorexia - clinical case........................................133Antenatal Visit - clinical case...............................119Anterior Drawer Test............................................82anti-hypertensive drugs.........................................10Apley's Scratch Test..............................................86Appendicitis..........................................................16Apprehension Sign................................................86Arrhythmias..........................................................31ASA.....................................................................31Asthma............................................................24, 45Asthma - clinical case..........................................103Athlete's foot........................................................13Atrial Fibrillation.............................................8, 102Atrial Fibrillation - clinical case...........................102Atrophic vaginitis..................................................39Back Pain - clinical case.......................................142Bacterial Meningitis..............................................49Bacterial Pneumonia .............................................46Bacterial Tracheitis................................................45Bacterial vaginosis.................................................39Basal Cell Carcinoma - clinical case.....................143Benign Prostatic Hyperplasia - clinical case..........144Bipolar disorder.....................................................57Bowstring test.......................................................78Breast Feeding - counseling.................................159Buerger's Test........................................................68Bulimia - clinical case..........................................134Burns....................................................................11Ca Oesophagus - clinical case..............................148Candidiasis...........................................................39Carpal Tunnel Syndrome - clinical case................145Cellulitis...............................................................13Cerebrovascular Attack - clinical case..................105Chest Pain - clinical case.....................................111Child abuse - counseling......................................160Chlamydia............................................................38Cluster headache...................................................22Cocaine Overdose.................................................59

Collateral Ligament Stability.................................82Community Acquired Pneumonia.........................25Congestive Cardiac Failure......................................8Congestive Heart Failure - clinical case................104COPD..................................................................24Crohn’s Disease.....................................................17Croup...................................................................48Deep Vein Thrombosis - clinical case...................146Delirium...............................................................52Delirium - clinical case........................................135Delirium Tremens.................................................36Dementia..............................................................55Dementia - clinical case.......................................136Depression............................................................56Depression - clinical case.....................................137Diabetes Mellitus..................................................14Diabetic Foot - clinical case.................................147Diabetic ketoacidosis.............................................31Diabetic Ketoacidosis............................................14Digoxin.................................................................32Digoxin Toxicity - clinical case............................106Diverticulitis.........................................................17Domestic violence - counseling............................161Dysfunctional Uterine Bleeding.............................40Dyslipidemia...........................................................9Dysmenorrhea.......................................................40Ectopic Pregnancy.................................................42Ectopic Pregnancy - clinical case.........................120Emergency contraception......................................41Empty Can Test ...................................................86Endometriosis.......................................................40Epiglottitis............................................................48Ethylene glycol .....................................................32Examination - Abdominal.....................................63Examination - Back/Spine.....................................77Examination - Breast.............................................90Examination - Cardiovascular................................65Examination - Central Nervous System ................71Examination - Elbow ...........................................87Examination - Foot and Ankle .............................83Examination - Hand and Wrist ............................88Examination - Hip ...............................................79Examination - Knee .............................................81Examination - Lower Limb Neurological .............75Examination - Mini Mental State .........................93Examination - Peripheral Vascular ........................67Examination - Respiratory ....................................69Examination - Shoulder........................................85Examination - Thyroid .........................................91Examination - Upper Limb Neurological ..............73External Rotation Lag Sign...................................86FABER...........................................................78, 80Failure to thrive - clinical case..............................126Febrile Seizures.....................................................49Febrile seizures - clinical case...............................127Femoral stretch test...............................................78Fibromyalgia.........................................................29Finkelstein's test....................................................89General Anxiety Disorder......................................54

Alphabetical Index

Genital herpes.......................................................38Genital warts ........................................................38Gerber Lift-Off Test.............................................86GI Bleed...............................................................34Golfer's Elbow......................................................87Gonorrhea............................................................38Gout.....................................................................27Group A Streptococcus.........................................48Group B Streptococcus..........................................41Hallucinogens.......................................................59Hawkins Impingement Sign..................................86Headache - clinical case.......................................110Heart Failure...........................................................8Helicobacter Pylori................................................17Hematemesis - clinical case.................................149Hemothorax - clinical case..................................156Hepatitis B............................................................18HIV......................................................................19Hormone Replacement Therapy............................41HRT - counseling...............................................162Horner's sydrome..................................................69Hyperemesis Gravidarum......................................42Hyperprolactinemia............................................15p.Hypertension.....................................................9, 32Hyperthyroidism...................................................15Hypoglycemia.......................................................32Hypothyroidism....................................................15Immunization - counseling..................................164Immunization Schedule.........................................50Impotence.............................................................16Impotence - clinical case......................................108Infectious Mononucleosis - clinical case...............107Infective Endocarditis............................................10Infertility - clinical case.......................................121Lachman Test.......................................................82Laryngotracheobronchitis......................................48Lasegue's sign.......................................................78Malaria.................................................................20Mammogram - counseling...................................163Mania...................................................................53Mania - clinical case............................................138McMurray's Test...................................................82Measles - clinical case..........................................128Meningitis............................................................21Meningitis - clinical case.....................................109Migraine...............................................................22Mood stabilizers....................................................57Myasthenia Gravis................................................23Neck Swelling - clinical case................................150Neer Impingement Sign........................................86Neonatal Jaundice - clinical case..........................129Obesity - counseling............................................165Obsessive-compulsive disorder ..............................55OCP Counseling - clinical case...........................122Opioid..................................................................33Opioid Intoxication...............................................59Osteoarthritis........................................................26Osteoporosis.........................................................26Ottawa Ankle rules...............................................84

Pain Abdomen - clinical case...............................151Panic attack...........................................................53Panic Attack - clinical case..................................139Panic disorder........................................................53Parkinson’s disease.................................................23Patellar Apprehension...........................................82Patellar Grind.......................................................82Pediculosis............................................................13Pelvic Inflammatory Disease..................................40Pelvic inflammatory disease - clinical case............123Pemberton's sign...................................................91Peptic ulcer disease................................................19Peripheral Vascular Disease - clinical case............152Pertussis................................................................48Phalen's test .........................................................89Phencyclidine........................................................59Placenta Previa - clinical case...............................124Plantar Fasciitis Test..............................................84Pneumonia - clinical case.....................................112Polymyalgia Rheumatica........................................28Post exposure - clinical case.................................113Post Operative fever - clinical case.......................153Post-traumatic stress disorder ...............................55Posterior Drawer Test............................................82Pre Eclampsia - clinical case................................125Pregnancy Induced Hypertension..........................41Primary nocturnal enuresis - clinical case.............130Psoriasis................................................................12Psychosis...............................................................56Pulmonary Embolism............................................25Pulmonary Embolism - clinical case....................114Pulmonary tuberculosis..........................................20Pyelonephritis.......................................................39Pyloric stenosis - clinical case..............................131Rabies...................................................................20Rheumatic Heart Disease......................................10Rheumatoid Arthritis............................................26Romberg’s test.......................................................72Scabies..................................................................13Schizophrenia - clinical case................................140Schober's Test.......................................................78Seizure disorder - clinical case.............................115Seizures.................................................................21Septic Arthritis.....................................................29sexual dysfunction.................................................58Sexually Transmitted Infection..............................38Shock....................................................................33Smoking...............................................................35Smoking - counseling..........................................167Social Phobia........................................................54Solitary lung nodule - clinical case.......................154Speech delay - clinical case..................................132Speed's Maneuver.................................................86Sprain...................................................................33Straight leg raising test..........................................78Streptococcal Pharyngitis......................................48Stroke...................................................................33Substance abuse.....................................................59Suicide - clinical case...........................................141

Alphabetical Index

Syphilis.................................................................38Talar Tilt Test.......................................................84TCA.....................................................................34Temporal arteritis..................................................28Temporal Arteritis - clinical case.........................116Tennis Elbow .......................................................87Tension headache..................................................22Tetanus.................................................................21Thomas test..........................................................80Thompson's Test...................................................84Thyroid mass - clinical case.................................155Tinea Cruris.........................................................13Tinel's sign............................................................89Trendelenberg test.................................................79

Trendelenburg Maneuver.......................................68Trichomonas vaginalis...........................................39Troisier's Sign.......................................................69Tylenol..................................................................50Ulcerative Colitis...................................................19Urinary tract infection...........................................29Urinary Tract Infection....................................39, 49Viral Hepatitis - clinical case...............................117Virchow's Node.....................................................69Vocal fremitus.......................................................70Vulvovaginitis........................................................39Warfarin...............................................................34Whooping Cough ................................................48Yergason test.........................................................86

Documents

NAC OSCE - A Comprehensive Review