NAC OSCE

A 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 OSCE

General Information ...............................................................................................................1
Registration for NAC OSCE ..................................................................................................1
Fees ........................................................................................................................................1
Examination station ................................................................................................................1
NAC OSCE scoring ...............................................................................................................2
Sample of Therapeutic written test ..........................................................................................2
Sample clinical case station .....................................................................................................3
Therapeutic Guidelines
Medicine
Cardiology ..............................................................................................................................7
Dermatology ........................................................................................................................11
Endocrinology ......................................................................................................................14
Gastroenterology ..................................................................................................................16
Hematology ..........................................................................................................................19
Infectious Diseases ................................................................................................................19
Neurology .............................................................................................................................21
Otolaryngology .....................................................................................................................23
Pulmonology ........................................................................................................................24
Rheumatology ......................................................................................................................26
Nephrology/Urology .............................................................................................................29
Emergency Medicine ............................................................................................................30
Counseling (smoking/alcohol) ...............................................................................................35
Obstetrics & Gynecology
Sexually transmitted infections ..............................................................................................38
Urinary tract infection ...........................................................................................................39
Vulvovaginitis .......................................................................................................................39
Pelvic inflammatory disease ...................................................................................................40
Dysfunctional uterine bleeding ..............................................................................................40
Dysmenorrhea ......................................................................................................................40
Endometriosis ......................................................................................................................40
Hormone replacement therapy ..............................................................................................41
Emergency contraception ......................................................................................................41
Group B Streptococcus in pregnancy .....................................................................................41
Pregnancy induced hypertension ...........................................................................................41
Ectopic pregnancy ................................................................................................................42
Hyperemesis gravidarum .......................................................................................................42
Drugs contraindicated in pregnancy ......................................................................................42
Pediatrics
Acute bronchiolitis ................................................................................................................45
Acute otitis media .................................................................................................................45
Asthma .................................................................................................................................45
Bacterial tracheitis ................................................................................................................45
Bacterial pneumonia .............................................................................................................46
Croup (Laryngotracheobronchitis) ........................................................................................48
Epiglottitis ...........................................................................................................................48
Streptococcal pharyngitis (Group A streptococcus) ................................................................48
Whooping cough (Pertussis) .................................................................................................48
Bacterial meningitis ..............................................................................................................49
Febrile seizures .....................................................................................................................49
Urinary tract infection ...........................................................................................................49
Allergic reaction ....................................................................................................................50
Anemia .................................................................................................................................50
Dose of tylenol .....................................................................................................................50
Immunization schedule .........................................................................................................50
 TABLE OF CONTENTS
Psychiatry
Delerium ..............................................................................................................................52
Mania ...................................................................................................................................53
Panic disorder .......................................................................................................................53
Social phobia ........................................................................................................................54
General anxiety disorder .......................................................................................................54
Obsessive compulsive disorder ...............................................................................................55
Post traumatic stress disorder ................................................................................................55
Dementia .............................................................................................................................55
Depression ............................................................................................................................56
Psychosis ..............................................................................................................................56
Mood stabilizers ...................................................................................................................57
Medications causing sexual dysfunction .................................................................................58
Substance abuse ....................................................................................................................59
Clinical Examination
Abdominal ...........................................................................................................................63
Cardiovascular .....................................................................................................................65
Peripheral vascular ................................................................................................................67
Respiratory examination ........................................................................................................69
Central nervous system ........................................................................................................71
Upper limb neurological .......................................................................................................73
Lower limb neurological .......................................................................................................75
Musculo-skeletal system : Spine/Back ...................................................................................77
Hip .......................................................................................................................................79
Knee .....................................................................................................................................81
Foot and ankle ......................................................................................................................83
Shoulder ...............................................................................................................................85
Elbow ...................................................................................................................................87
Hand and wrist .....................................................................................................................88
Breast examination ................................................................................................................90
Thyroid ................................................................................................................................91
Mini Mental State Examination ............................................................................................93
Clinical cases
Protocol for history taking .....................................................................................................99
Medicine
Atrial fibrillation .................................................................................................................102
Asthma ...............................................................................................................................103
Congestive heart failure .......................................................................................................104
Cerebrovascular attack .........................................................................................................105
Digoxin toxicity ..................................................................................................................106
Infectious mononucleosis (sore throat) .................................................................................107
Impotence ...........................................................................................................................108
Meningitis ..........................................................................................................................109
Migraine (Headache) ..........................................................................................................110
Myocardial Infarction(Chest pain) .......................................................................................111
Pneumonia ..........................................................................................................................112
Post exposure prophylaxis for HIV ......................................................................................113
Pulmonary embolism ..........................................................................................................114
Seizure disorder ...................................................................................................................115
Temporal arteritis ................................................................................................................116
Viral hepatitis .....................................................................................................................117
Obstetrics and Gynecology
Abortion .............................................................................................................................118
Antenatal visit .....................................................................................................................119
Ectopic pregnancy ...............................................................................................................120
 TABLE OF CONTENTS
Infertility ............................................................................................................................121
OCP counseling ..................................................................................................................122
Pelvic inflammatory disease .................................................................................................123
Placenta previa ....................................................................................................................124
Pre eclampsia ......................................................................................................................125
Pediatrics
Failure to thrive ...................................................................................................................126
Febrile seizure .....................................................................................................................127
Measles ...............................................................................................................................128
Neonatal jaundice ................................................................................................................129
Primary nocturnal enuresis ..................................................................................................130
Pyloric stenosis ....................................................................................................................131
Speech delay .......................................................................................................................132
Psychiatry
Anorexia .............................................................................................................................133
Bulimia ...............................................................................................................................134
Delirium .............................................................................................................................135
Dementia ............................................................................................................................136
Depression ..........................................................................................................................137
Mania .................................................................................................................................138
Panic attack .........................................................................................................................139
Schizophrenia .....................................................................................................................140
Suicide ................................................................................................................................141
Surgery
Back Pain ............................................................................................................................142
Basal cell carcinoma ............................................................................................................143
Benign prostatic hyperplasia ................................................................................................144
Carpal Tunnel Syndrome .....................................................................................................145
Deep Vein Thrombosis ........................................................................................................146
Diabetic foot .......................................................................................................................147
Difficulty swallowing (Ca oesophagus ) ...............................................................................148
Hematemesis ......................................................................................................................149
Neck swelling ......................................................................................................................150
Pain abdomen .....................................................................................................................151
Peripheral vascular disease ...................................................................................................152
Post operative fever .............................................................................................................153
Solitary lung nodule ............................................................................................................154
Thyroid mass ......................................................................................................................155
Trauma ...............................................................................................................................156
Counseling
Breast feeding .....................................................................................................................159
Child abuse .........................................................................................................................160
Domestic violence ...............................................................................................................161
Hormone replacement therapy ............................................................................................161
Mammogram ......................................................................................................................163
Immunization .....................................................................................................................164
Obesity ...............................................................................................................................165
Smoking .............................................................................................................................167
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Introduction to NAC OSCE | General Info 1

Introduction to NAC OSCE

General 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 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.

Fees
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
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

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 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 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 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?
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Therapeutic Guidelines
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Therapeutic Guidelines | Medicine 7

Therapeutic Guidelines

Medicine

1. Cardiology
Acute Myocardial Infarction : Immediate management in ER
ACUTE MI TREATMENT
1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto MNEMONIC
15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. B : Beta Blockers
2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID. M : Morphine Sulphate
3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn O : Oxygen
N : Nitroglycerin
(If pain not relieved with 3 Sublingual Nitroglycerins) A : Aspirin
4. Oxygen by nasal cannula at 4 liters per minute
5. 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

Drugs Benefits Side effects Contraindication

ACE Inhibitors ↓ mortality Hypotension/dizziness Bilateral renal artery

Ramipril – 10mg hs Prevents ventricular remodelling Hyperkalemia stenosis
Lisinopril – 10 mg od ↓ proteinuria Angioedema Hx of angioedema
Enalapril – 20mg od Renal insufficiency Pregnancy
Captopril - 50 mg tid Cough, taste changes

ARB ↓ mortality Angioedema

Valsartan – 160mg bid
Candesartan – 32 mg od
Beta Blocker
Metoprolol – 100mg bid
Atenolol – 100mg od
Carvedilol – 25mg bid
Propranolol – 60-80 tid
↓ proteinuria Cough, taste changes
↓ mortality Decreases BP & HR Severe/poorly
↓ sudden death, reinfarction & Dizziness, fatigue controlled asthma
nd
arrhythmias Sexual dysfunction 2 /3rd degree heart
Cardioselective : preferred for block
May mask hypoglycemia
mild asthma and diabetes HR<50, SBP<90
Increase risk of
cardiogenic shock Cocaine use

Statins
Atorvastatin – 10mg od
Simvastatin – 20-40mg od
Anti-platelets
ASA – 80-162mg od
Clopidogrel – 75mg od
Warfarin – 1-10mg od
↓ mortality in post MI patients GI upset, muscle aches, Active liver disease,
with high cholesterol myopathy, rhabdomyo- alcoholics, pregnancy
lysis, Impotence
↓ vascular events GI upset, Recent/active
hypersensitivity bleeding
GI bleed GI intolerance or ASA
allergy
8 NAC OSCE | A Comprehensive Review

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 CHF TREATMENT MNEMONIC

L : Lasix
• Oxygen by nasal cannula at 4 liters per minute. M : Morphine Sulphate
N : Nitroglycerin
• Inj Furosemide (Lasix) 10 mg IV stat.
O : Oxygen
• Inj Morphine sulfate IV 2-5 mg every 5-30 min prn. P : Positive airway pressure
• Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. P : Position > 45 degrees
• Position of patient > 45 degrees. D : Dopamine (indicated in
cardiogenic shock and
hypotension)
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.
Clinical Examination
Clinical Examination 91

Thyroid 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 myxedema
Loss of 1/3rd of eyebrows
Hair – texture/alopecia
Exophthalmos (look from behind patient), lid lag
Ophthalmoplegia (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 eythema
Pemberton'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.
92 NAC OSCE | A Comprehensive Review

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 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 - Onset P – Past medical history

C - Course A - Allergies
D - Duration M - Medication
P - Place H – Hospitalizations
Q - Quality U – Urinary problems
R - Radiation G – GIT problems
S - Severity S - Sleep
T - Timing F – Family history
U – You (associated with your daily activities) O – Obstetrical history
V – Deja vu (Has it happened before?) S – Social history
A – Aggravating factors S – Sexual history
A – Alleviating factors
A – Associated symptoms
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.”
102 NAC OSCE | A Comprehensive Review

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 Past History

• OCD PQRST UV + AAA • Do you have any medical illnesses?
• How did it start? Sudden or gradual. • Are you allergic to any medications?
• Is it getting worse/better or no changes in • Any surgeries in the past?
the symptoms? • Past h/o recurrent infections?
• Duration of palpitations?
• Associated with chest discomfort? Family and Social History
• Describe the type of chest discomfort? • Do you smoke? Duration & frequency.
• Do you have chest pain? • Do you consume alcohol? Duration &
• Any shortness of breath? frequency.
• Any dizziness/light headedness? • Do you take any recreational drugs?
• Any fever/cough/nausea/vomiting? • Any family history of cancers/ medical
• Any hemoptysis? illnesses?
• 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?

Differential Diagnosis Management

Atrial fibrillation secondary to: • Treat the primary cause.
1. Congestive heart failure. • Admit in cardiac care unit.
2. Ischemic heart disease. • Rate control by beta blockers, calcium
3. Hypertension. channel blockers or digoxin.
4. Thyroid disease. • Anticoagulation with heparin, then warfarin.
• Rhythm control by electro or medical
Investigations cardioversion.
• CBC, electrolytes, glucose. • Assess Stroke risk by using CHADS2 score.
• LFT, RFT, TSH.
• CK, LDH, Cardiac enzymes.
• 12 lead ECG.
• Echocardiogram.
• Chest X ray.
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 • Who are the biological parents of the

• 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 Family and Social History
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?
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?
• 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........................................118
Acetaminophen ....................................................30
Acne.....................................................................11
Acute Bronchiolitis...............................................45
Acute Cholecystitis...............................................19
acute confusional state...........................................52
Acute Gastroenteritis............................................16
Acute Myocardial Infarction....................................7
Acute Otitis Media ..............................................45
Acute Pancreatitis..................................................17
Acute Pharyngitis..................................................23
Acute Pyelonephritis.............................................30
Acute Sinusitis......................................................23
Alcohol.................................................................35
Alcohol withdrawal..........................................30, 59
Allen Test..............................................................68
Allergic reaction....................................................50
Allergic Reaction...................................................30
Anaphylaxis...........................................................30
Anemia............................................................19, 50
Ankle Anterior Drawer Test .................................84
Anorexia - clinical case........................................133
Antenatal Visit - clinical case...............................119
Anterior Drawer Test............................................82
anti-hypertensive drugs.........................................10
Apley's Scratch Test..............................................86
Appendicitis..........................................................16
Apprehension Sign................................................86
Arrhythmias..........................................................31
ASA.....................................................................31
Asthma............................................................24, 45
Asthma - clinical case..........................................103
Athlete's foot........................................................13
Atrial Fibrillation.............................................8, 102
Atrial Fibrillation - clinical case...........................102
Atrophic vaginitis..................................................39
Back Pain - clinical case.......................................142
Bacterial Meningitis..............................................49
Bacterial Pneumonia .............................................46
Bacterial Tracheitis................................................45
Bacterial vaginosis.................................................39
Basal Cell Carcinoma - clinical case.....................143
Benign Prostatic Hyperplasia - clinical case..........144
Bipolar disorder.....................................................57
Bowstring test.......................................................78
Breast Feeding - counseling.................................159
Buerger's Test........................................................68
Bulimia - clinical case..........................................134
Burns....................................................................11
Ca Oesophagus - clinical case..............................148
Candidiasis...........................................................39
Carpal Tunnel Syndrome - clinical case................145
Cellulitis...............................................................13
Cerebrovascular Attack - clinical case..................105
Chest Pain - clinical case.....................................111
Child abuse - counseling......................................160
Chlamydia............................................................38
Cluster headache...................................................22
Cocaine Overdose.................................................59
Collateral Ligament Stability.................................82
Community Acquired Pneumonia.........................25
Congestive Cardiac Failure......................................8
Congestive Heart Failure - clinical case................104
COPD..................................................................24
Crohn’s Disease.....................................................17
Croup...................................................................48
Deep Vein Thrombosis - clinical case...................146
Delirium...............................................................52
Delirium - clinical case........................................135
Delirium Tremens.................................................36
Dementia..............................................................55
Dementia - clinical case.......................................136
Depression............................................................56
Depression - clinical case.....................................137
Diabetes Mellitus..................................................14
Diabetic Foot - clinical case.................................147
Diabetic ketoacidosis.............................................31
Diabetic Ketoacidosis............................................14
Digoxin.................................................................32
Digoxin Toxicity - clinical case............................106
Diverticulitis.........................................................17
Domestic violence - counseling............................161
Dysfunctional Uterine Bleeding.............................40
Dyslipidemia...........................................................9
Dysmenorrhea.......................................................40
Ectopic Pregnancy.................................................42
Ectopic Pregnancy - clinical case.........................120
Emergency contraception......................................41
Empty Can Test ...................................................86
Endometriosis.......................................................40
Epiglottitis............................................................48
Ethylene glycol .....................................................32
Examination - Abdominal.....................................63
Examination - Back/Spine.....................................77
Examination - Breast.............................................90
Examination - Cardiovascular................................65
Examination - Central Nervous System ................71
Examination - Elbow ...........................................87
Examination - Foot and Ankle .............................83
Examination - Hand and Wrist ............................88
Examination - Hip ...............................................79
Examination - Knee .............................................81
Examination - Lower Limb Neurological .............75
Examination - Mini Mental State .........................93
Examination - Peripheral Vascular ........................67
Examination - Respiratory ....................................69
Examination - Shoulder........................................85
Examination - Thyroid .........................................91
Examination - Upper Limb Neurological ..............73
External Rotation Lag Sign...................................86
FABER...........................................................78, 80
Failure to thrive - clinical case..............................126
Febrile Seizures.....................................................49
Febrile seizures - clinical case...............................127
Femoral stretch test...............................................78
Fibromyalgia.........................................................29
Finkelstein's test....................................................89
General Anxiety Disorder......................................54
Alphabetical Index
Genital herpes.......................................................38
Genital warts ........................................................38
Gerber Lift-Off Test.............................................86
GI Bleed...............................................................34
Golfer's Elbow......................................................87
Gonorrhea............................................................38
Gout.....................................................................27
Group A Streptococcus.........................................48
Group B Streptococcus..........................................41
Hallucinogens.......................................................59
Hawkins Impingement Sign..................................86
Headache - clinical case.......................................110
Heart Failure...........................................................8
Helicobacter Pylori................................................17
Hematemesis - clinical case.................................149
Hemothorax - clinical case..................................156
Hepatitis B............................................................18
HIV......................................................................19
Hormone Replacement Therapy............................41
HRT - counseling...............................................162
Horner's sydrome..................................................69
Hyperemesis Gravidarum......................................42
Hyperprolactinemia............................................15p.
Hypertension.....................................................9, 32
Hyperthyroidism...................................................15
Hypoglycemia.......................................................32
Hypothyroidism....................................................15
Immunization - counseling..................................164
Immunization Schedule.........................................50
Impotence.............................................................16
Impotence - clinical case......................................108
Infectious Mononucleosis - clinical case...............107
Infective Endocarditis............................................10
Infertility - clinical case.......................................121
Lachman Test.......................................................82
Laryngotracheobronchitis......................................48
Lasegue's sign.......................................................78
Malaria.................................................................20
Mammogram - counseling...................................163
Mania...................................................................53
Mania - clinical case............................................138
McMurray's Test...................................................82
Measles - clinical case..........................................128
Meningitis............................................................21
Meningitis - clinical case.....................................109
Migraine...............................................................22
Mood stabilizers....................................................57
Myasthenia Gravis................................................23
Neck Swelling - clinical case................................150
Neer Impingement Sign........................................86
Neonatal Jaundice - clinical case..........................129
Obesity - counseling............................................165
Obsessive-compulsive disorder ..............................55
OCP Counseling - clinical case...........................122
Opioid..................................................................33
Opioid Intoxication...............................................59
Osteoarthritis........................................................26
Osteoporosis.........................................................26
Ottawa Ankle rules...............................................84
Pain Abdomen - clinical case...............................151
Panic attack...........................................................53
Panic Attack - clinical case..................................139
Panic disorder........................................................53
Parkinson’s disease.................................................23
Patellar Apprehension...........................................82
Patellar Grind.......................................................82
Pediculosis............................................................13
Pelvic Inflammatory Disease..................................40
Pelvic inflammatory disease - clinical case............123
Pemberton's sign...................................................91
Peptic ulcer disease................................................19
Peripheral Vascular Disease - clinical case............152
Pertussis................................................................48
Phalen's test .........................................................89
Phencyclidine........................................................59
Placenta Previa - clinical case...............................124
Plantar Fasciitis Test..............................................84
Pneumonia - clinical case.....................................112
Polymyalgia Rheumatica........................................28
Post exposure - clinical case.................................113
Post Operative fever - clinical case.......................153
Post-traumatic stress disorder ...............................55
Posterior Drawer Test............................................82
Pre Eclampsia - clinical case................................125
Pregnancy Induced Hypertension..........................41
Primary nocturnal enuresis - clinical case.............130
Psoriasis................................................................12
Psychosis...............................................................56
Pulmonary Embolism............................................25
Pulmonary Embolism - clinical case....................114
Pulmonary tuberculosis..........................................20
Pyelonephritis.......................................................39
Pyloric stenosis - clinical case..............................131
Rabies...................................................................20
Rheumatic Heart Disease......................................10
Rheumatoid Arthritis............................................26
Romberg’s test.......................................................72
Scabies..................................................................13
Schizophrenia - clinical case................................140
Schober's Test.......................................................78
Seizure disorder - clinical case.............................115
Seizures.................................................................21
Septic Arthritis.....................................................29
sexual dysfunction.................................................58
Sexually Transmitted Infection..............................38
Shock....................................................................33
Smoking...............................................................35
Smoking - counseling..........................................167
Social Phobia........................................................54
Solitary lung nodule - clinical case.......................154
Speech delay - clinical case..................................132
Speed's Maneuver.................................................86
Sprain...................................................................33
Straight leg raising test..........................................78
Streptococcal Pharyngitis......................................48
Stroke...................................................................33
Substance abuse.....................................................59
Suicide - clinical case...........................................141
Alphabetical Index
Syphilis.................................................................38
Talar Tilt Test.......................................................84
TCA.....................................................................34
Temporal arteritis..................................................28
Temporal Arteritis - clinical case.........................116
Tennis Elbow .......................................................87
Tension headache..................................................22
Tetanus.................................................................21
Thomas test..........................................................80
Thompson's Test...................................................84
Thyroid mass - clinical case.................................155
Tinea Cruris.........................................................13
Tinel's sign............................................................89
Trendelenberg test.................................................79
Trendelenburg Maneuver.......................................68
Trichomonas vaginalis...........................................39
Troisier's Sign.......................................................69
Tylenol..................................................................50
Ulcerative Colitis...................................................19
Urinary tract infection...........................................29
Urinary Tract Infection....................................39, 49
Viral Hepatitis - clinical case...............................117
Virchow's Node.....................................................69
Vocal fremitus.......................................................70
Vulvovaginitis........................................................39
Warfarin...............................................................34
Whooping Cough ................................................48
Yergason test.........................................................86