NAC OSCE Exam — Questions and Answers

Question 1: A 25-year-old woman presents with acute onset pleuritic chest pain, dyspnoea, and a history of oral contraceptive use. Which investigation should be ordered FIRST according to Canadian guidelines?

CT pulmonary angiography (CTPA) after pre-test probability assessment using the Wells PE score (Correct answer)
Echocardiogram to rule out pericarditis
Arterial blood gas as the definitive test
Ventilation-perfusion (V/Q) scan as first line

Correct answer: CT pulmonary angiography (CTPA) after pre-test probability assessment using the Wells PE score

Canadian guidelines recommend calculating the Wells PE score first; if score is high or D-dimer is elevated in low/intermediate probability, CTPA is the first-line imaging choice.

Question 2: A 30-year-old woman has episodic hypertension, headache, palpitations, and diaphoresis. Which investigation is MOST appropriate to screen for phaeochromocytoma according to Canadian Endocrine Society guidelines?

MRI adrenal glands without biochemical confirmation
Clonidine suppression test as first line
24-hour urinary metanephrines or plasma free metanephrines (Correct answer)
24-hour urinary catecholamines alone

Correct answer: 24-hour urinary metanephrines or plasma free metanephrines

Canadian Endocrine Society guidelines recommend plasma free metanephrines or 24-hour urinary fractionated metanephrines as first-line biochemical screening for phaeochromocytoma due to superior sensitivity.

Question 3: When breaking bad news in a Canadian NAC OSCE station using the SPIKES protocol, what does the 'P' stand for?

Prognosis (expected outcome)
Permission (ask before sharing news)
Plan (treatment options)
Perception (assess what the patient already knows) (Correct answer)

Correct answer: Perception (assess what the patient already knows)

In the SPIKES protocol, 'P' stands for Perception — assessing the patient's current understanding before delivering news prevents information mismatch and supports patient-centred communication.

Question 4: A patient presents with shortness of breath. Which question BEST helps differentiate between cardiac and pulmonary causes?

Do you smoke cigarettes?
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)
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 5: During a respiratory examination, you find dullness to percussion, reduced breath sounds, and absent tactile fremitus over the right lower zone. What is the MOST likely cause?

Consolidation
Pneumothorax
Pleural thickening
Pleural effusion (Correct answer)

Correct answer: Pleural effusion

Pleural effusion classically produces dullness to percussion, reduced breath sounds, and absent tactile fremitus; consolidation would preserve or increase fremitus and produce bronchial breath sounds.

Question 6: A 48-year-old man with a 30 pack-year smoking history has a pulmonary function test showing FEV1/FVC ratio of 0.62 (post-bronchodilator) and FEV1 55% predicted. According to GOLD criteria, how is this classified?

Moderate COPD (GOLD 2) (Correct answer)
Mild COPD (GOLD 1)
Severe COPD (GOLD 3)
Very severe COPD (GOLD 4)

Correct answer: Moderate COPD (GOLD 2)

A post-bronchodilator FEV1/FVC <0.70 confirms obstructive disease; FEV1 50–79% predicted classifies this as GOLD Grade 2 (Moderate) COPD.

Question 7: According to the Canadian federal law (MAID legislation, Bill C-7 2021), which patient is eligible for Medical Assistance in Dying (MAiD) under Track 1?

An adult with a grievous and irremediable medical condition where natural death is reasonably foreseeable (Correct answer)
A minor aged 16-17 with parental consent
A patient with a mental illness as the sole underlying condition
Any adult with a terminal illness regardless of decision-making capacity

Correct answer: An adult with a grievous and irremediable medical condition where natural death is reasonably foreseeable

Bill C-7 (2021) amended MAID eligibility; Track 1 (no 90-day assessment period) applies when natural death is reasonably foreseeable; Track 2 applies when it is not; mental illness as sole underlying condition remains under a sunset clause.

Question 8: A 4-year-old child is brought in with a limp. On examination, the hip is held in flexion, abduction, and external rotation. What is the MOST likely diagnosis?

Transient synovitis
Septic arthritis of the hip (Correct answer)
Developmental dysplasia of the hip
Legg-Calvé-Perthes disease

Correct answer: Septic arthritis of the hip

Septic arthritis presents with the hip held in the position of maximum capsular volume (flexion, abduction, external rotation) and is a surgical emergency; fever and elevated inflammatory markers distinguish it from transient synovitis.

Question 9: A 32-year-old woman at 10 weeks gestation has Hgb 92 g/L, MCV 73 fL, and serum ferritin 6 μg/L (normal >15). What is the most likely diagnosis?

Physiologic anemia of pregnancy
Iron deficiency anemia (Correct answer)
Beta-thalassemia trait
Folate deficiency anemia

Correct answer: Iron deficiency anemia

Microcytic anemia (low MCV) with a markedly low serum ferritin confirms iron deficiency as the cause, which is the most common nutritional deficiency in pregnancy.

Question 10: A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Which single test is MOST appropriate to confirm the suspected diagnosis?

T3 level
Anti-TPO antibodies
TSH (thyroid-stimulating hormone) (Correct answer)
Free T4 alone

Correct answer: TSH (thyroid-stimulating hormone)

TSH is the most sensitive first-line test for hypothyroidism, consistent with Canadian guidelines; a high TSH with low free T4 confirms primary hypothyroidism.

Question 11: 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?
Do you drink alcohol? Do you use recreational drugs?
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)
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 12: During a neurological examination, you test cranial nerve VII. Which finding would indicate an upper motor neuron (UMN) lesion rather than a lower motor neuron (LMN) lesion?

Complete unilateral facial paralysis including the forehead
Hyperacusis on the affected side
Loss of taste on the anterior two-thirds of the tongue
Forehead sparing on the side of facial weakness (Correct answer)

Correct answer: Forehead sparing on the side of facial weakness

UMN lesions spare the forehead due to bilateral cortical representation of the frontalis muscle, whereas LMN lesions (e.g., Bell's palsy) cause complete unilateral facial weakness including the forehead.

NAC OSCE Exam

The National Assessment Collaboration Objective Structured Clinical Examination (NAC OSCE) evaluates international medical graduates on clinical skills including history taking, physical examination, clinical reasoning, and communication skills required for Canadian medical licensure.

Questions

240 min

Time Limit

65%

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