crackthenac 8 case for the nac osce

8/15/2019 CrackTheNac 8 Case for the NAC OSCE

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8 CASES FOR THE NAC OSCE

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Thanks for downloading our free ebook to help you prepare for the NAC OSCE. We definitely appreciatehow stressful preparing for this exam can be and how important a top score is to your residencyapplications and eventual practice in Canada. We also understand how there is virtually 0 informationon 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 rightanswers to these cases; they are simply opening paragraphs, similar to ones you may see in the NACOSCE. These should be used as a guide to help you think critically, act, and work your way towards totalpreparation. We suggest you read the opening statement and then explore the checklists. Consider whatyou would ask, what you would do, and how you would proceed with your exam. Think about commonissues, and the most likely answers to the examiner questions. As well we’ve added some study tips andsuggestions at the end of each case.

One final piece of advice: practice, practice, practice, grab a friend, a sibling, a colleague and rehearseevery physical exam, rehearse every algorithm for questions, and know your public health and medico-legal guidelines inside and out.


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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 Onseto Locationo Precipitating factorso Alleviating factorso Associated symptomso Qualityo Radiationo Severityo Timing/duration

Identifies risk factors for heart diseaseo Past medical historyo Family history of heart disease or risk factorso Smoking historyo Illicit Drug use (especially cocaine)o Hypertensiono

Lipids/cholesterolo Recent stressorso Exercise tolerance

Focused review of systemso Heartburn/GERD symptomso Pain with movement/palpationo Medicationso Allergieso Summarizes historyo 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 managi ng “panic attacks”


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Tips

1. Always rule out the most serious causes first.2. Use clear open ended questions.3. Write down the most common Dx on your notepad as you read the case.4. 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 youorder 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 onlydiagnose, but communicate common and important health issues in a real setting.


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Case 2

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

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 distensiono Looks for bruising, scars, mass

Auscultationo Listens for bowel soundso Listens for bruits

Percussiono Percusses abdomeno Percusses livero Percusses spleeno Comments on tenderness Palpationo Light palpationo Deep palpationo Requests Digital rectal examo Requests external genital examo Palpates for

Appendicitis Palpates for AAA Hepatomegaly

Makes appropriate closing remarks Examiner question:

o What tests would you like to performo Based on attached image (Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID:

17788)


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Case 3:

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

Introduces self to patient Washes Hands Establishes reason for visit History

o Charactero Onseto Durationo Frequencyo What makes it worse? What makes it better?o Current medications

Asks abouto Smokingo Paino Exposure to chemicals/irritantso Exposure to pets/birdso Nocturnal cougho Exercise Toleranceo Shortness of breatho Snoringo Carpetingo Fireplace

Previous Medical History Allergies Social History

o Alcoholo Tobaccoo Marijuanao Illicit drugs

Family History


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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 ifsymptoms 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 limitedto: using an aerochamber, checking blood sugar, injecting insulin, various forms ofcontraception, etc. Don’t be surprised if you are asked to cou nsel 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 torefer 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 isunlikely that you will be asked to choose a specific dose or a frequency, but knowing that X isfirst line, Y is added to first line, and Z is third in line for treatment is important for both the NACOSCE 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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Case 4:

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

Introduces self to parents Establishes reason for visit Washes hands Relevant history Asks about presence of

o Bloodo Oilyo Puso Mucuso Colour/Consistencyo Fowl smellingo Frequencyo 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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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? Whenwould 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 tostandardize for a national exam, it is likely that you will see the parent/caretaker of a child andbe 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 vaccinationappointment?


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Case 5

Jennifer Stevens is a 17 year old female that presents to the clinic for personal reasons. Pleasedetermine 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 Onseto Durationo Charactero Sexual history

Rape? Abuse?o Sexual orientationo Contraception and barrier protectiono Obstetric historyo Menstrual historyo Abnormal bleedingo Urinary symptoms

Previous medical historyo Previous STI/Pregnancy/ectopico Surgery

Medicationso

Oral ABXo Oral Contraception

Social Historyo Smokingo Alcoholo Drugso Work lifeo School lifeo Who is she at home with?


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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. Social cases involving youth/young adults are common in nearly all 4 th year OSCEs.2. What diseases must be reported to public health?3. Does the partner have to be notified?4. What are the laws surrounding HIV?5. What if the individual reports sexual abuse? Rape? Sex with a minor/adult?6. What is the age of consent in Canada?

7. What if they ask you to not inform their parents?8. What are the laws surrounding abortion?


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Case 6

Mr. Samuel Jones is a 63 year old man with a 20 year history of diabetes he presents to your clinic todayfor 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 feeto Examines proprioception of great toeo Ankle jerk reflex

Closes interview


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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 byphysicians 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 anddiagnose classic presentations.

2. There are no tricks, if the instructions ask you to perform a foot exam, that’s all you are requiredto do. There will be no secret malignancy lurking in the case. No secret social issues hidden in afoot exam.

3. Re-read the instructions if you get lost. They are generally very clear and concise. They willinstruct 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 fo r physicalexam stations, talk, talk, and talk more so you leave no doubt in the examiner’ s mind that youknow your stuff and you know what you are doing and why.


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Case 7

Mrs. Abigail Johnson is brought into to your clinic by her 30 year old son for a renewal of her narcoticsprescription. Please explore the reasons for her visit and address any concerns she may have. Do notperform a physical exam.

Introduces self to patient Washes hands Establishes reason for visit Establishes reason for narcotics prescription Assesses Pain

o Locationo Onseto Durationo Intensityo Provocative/Palliative factors

Assesses narcotic useo How often does she take the pillso Does she take any other pain medicationo Sleep qualityo Does anyone else have access to her medicationo When was her last renewalo 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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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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Case 8

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

Introduces self to patient Washes hands Establishes reason for visit History of Present Complaint

o Charactero Onseto Intensityo Durationo Aggravating/Mitigating factors

Asks abouto Paino Fullnesso Difficulty voidingo Blood in urineo Fever/chillso Weight losso Kidney stones

Previous Medical Historyo

Malignancyo Obstetric Historyo Surgeryo Renal historyo Bladder Historyo Diabetes

MEDSo Anticholinergico Diuretics

Social Historyo Smokingo Alcoholo Drugso Sex historyo Activities of daily livingo Support at home


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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 commonpresentations 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 shortcomingsof knowledge with communication, but you cannot make up for poor communication withknowing everything.


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crackthenac 8 case for the nac osce

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