NAC OSCE History Taking 2 — Questions and Answers
Question 1: A patient presents with shortness of breath. Which question BEST helps differentiate between cardiac and pulmonary causes?
- What colour is your sputum?
- Is the shortness of breath worse when lying flat (orthopnea) and do you wake up at night gasping for air (paroxysmal nocturnal dyspnea)? (Correct answer)
- Do you smoke cigarettes?
- Have you travelled recently?
Correct answer: Is the shortness of breath worse when lying flat (orthopnea) and do you wake up at night gasping for air (paroxysmal nocturnal dyspnea)?
Orthopnea (breathlessness when lying flat) and paroxysmal nocturnal dyspnea (PND — waking from sleep with breathlessness) are classic features of heart failure. While they can occur in severe lung disease, these symptoms specifically suggest fluid redistribution when supine, pointing to a cardiac cause. This distinction is critical for guiding further investigation.
Question 2: When interviewing a patient who is a poor historian, which technique is MOST effective?
- Ask only yes/no questions to speed up the interview
- Use open-ended questions initially, then focused closed questions, summarize frequently, and use collateral information from family or records (Correct answer)
- Skip the history and proceed directly to investigations
- Ask a colleague to take the history instead
Correct answer: Use open-ended questions initially, then focused closed questions, summarize frequently, and use collateral information from family or records
With poor historians, begin with open-ended questions to let them share what they can, then use focused questions to fill gaps. Summarize frequently to verify accuracy. Collateral information from family, caregivers, or medical records is invaluable. This structured approach maximizes information gathering while maintaining patient dignity.
Question 3: A patient mentions they have been feeling 'down.' Which screening questions are part of the PHQ-2 for depression?
- Have you lost weight recently? Do you have trouble sleeping?
- Over the past 2 weeks, have you had little interest or pleasure in doing things? Have you been feeling down, depressed, or hopeless? (Correct answer)
- Do you drink alcohol? Do you use recreational drugs?
- Have you had any thoughts of harming others? Do you hear voices?
Correct answer: Over the past 2 weeks, have you had little interest or pleasure in doing things? Have you been feeling down, depressed, or hopeless?
The PHQ-2 consists of two screening questions about the core symptoms of depression over the past 2 weeks: (1) loss of interest or pleasure (anhedonia) and (2) feeling down, depressed, or hopeless (low mood). A positive screen should prompt the full PHQ-9 assessment. These two questions have high sensitivity for major depressive disorder.
Question 4: When taking a sexual history in the NAC OSCE, which approach is considered BEST practice?
- Avoid the topic as it is too personal
- Normalize the questions, use non-judgemental language, ask about gender of partners, contraception, STI history, and ensure confidentiality (Correct answer)
- Only ask about sexual history if the patient has genital symptoms
- Ask the patient to fill out a questionnaire instead
Correct answer: Normalize the questions, use non-judgemental language, ask about gender of partners, contraception, STI history, and ensure confidentiality
A sexual history is a routine part of a complete medical assessment. Best practice includes normalizing ('I ask all my patients these questions'), using non-judgemental inclusive language, asking about the gender of sexual partners, number of partners, contraception use, STI testing and history, and ensuring confidentiality. The NAC OSCE assesses comfort and competence in this area.
Question 5: A 65-year-old patient presents with confusion. Which elements of the history are MOST important to obtain from a collateral source?
- The patient's dietary preferences and exercise habits
- The timeline of confusion onset (acute vs gradual), baseline cognitive function, recent medication changes, recent falls, and new symptoms such as fever or urinary symptoms (Correct answer)
- The patient's work history and education level
- The patient's insurance coverage and next of kin
Correct answer: The timeline of confusion onset (acute vs gradual), baseline cognitive function, recent medication changes, recent falls, and new symptoms such as fever or urinary symptoms
In acute confusion (delirium), collateral history is essential because the patient may be unable to provide reliable information. The most critical elements are: baseline cognition (is this new?), timeline (acute suggests delirium vs gradual suggests dementia), recent medication changes (common cause), recent infections, falls, and functional decline. This information guides the workup for reversible causes.
Question 6: In the NAC OSCE, what is the significance of asking about the patient's 'ideas, concerns, and expectations' (ICE)?
- It is not important and wastes valuable station time
- It demonstrates patient-centred care by understanding what the patient thinks is wrong, what worries them most, and what they hope to achieve from the visit (Correct answer)
- It is only relevant in psychiatric stations
- It replaces the need for a thorough medical history
Correct answer: It demonstrates patient-centred care by understanding what the patient thinks is wrong, what worries them most, and what they hope to achieve from the visit
ICE (Ideas, Concerns, Expectations) is a cornerstone of patient-centred communication assessed in the NAC OSCE. Understanding what the patient thinks is causing their symptoms, what concerns them most, and what they hope for from the encounter improves diagnostic accuracy, patient satisfaction, and adherence. It is relevant in every station, not just psychiatric ones.
NAC OSCE History Taking 2
A patient presents with shortness of breath.
Which question BEST helps differentiate between cardiac and pulmonary causes?