Introduction

How to use this book

Clinical skills exams—sometimes called “objective structured clinical examinations” or OSCEs—are a rite of passage for all physicians in training. These exams include the MCCQE II and the Certification Examination in Family Medicine in Canada, and equivalent exams in other countries such as the USMLE Step 2 CS in the United States.

This book is designed to help you prepare for these exams. Although simply reading through the cases in this book will be useful, the best way to study for a clinical skills exam is to practice. Groups of 3 or 4 work best, assigned to the following roles:

- Candidate: reads aloud a case from the list of cases at the back of the book. Reading aloud ensures that everyone knows the boundaries of the task. The candidate should then “perform the task” by formulating questions to ask the patient, or describing other procedures such as physical examinations or investigations, as required.

- Examiner: uses the notes for the case to formulate one or two pertinent questions to ask the candidate and to remind the candidate of any crucial steps they may have missed.

- Observers: help debrief the task. We recommend that observers pay particular attention to skills such as: communicating clearly and respectfully; setting appropriate priorities; engaging issues of medical ethics as needed; and resolving clinical situations that require the expertise of specialists.

Work through all the cases in the book in this way, changing roles each time.

Each case has time limit—either 5 minutes or 10 minutes—in keeping with the protocols for the Canadian clinical skills exams. In some instances, in an effort to be comprehensive, the cases set up more tasks than a candidate could realistically accomplish within the assigned time. It is still useful, however, to set a timer or stopwatch for the assigned time, to get a feel for “how long you have.”

Take the time to work through all the cases thoroughly and thoughtfully, so start at least a few months in advance of the exam. This will allow you to use each case to its fullest—exploring different issues and questions that each could contain—and allow you to gain some level of comfort and confidence in the face of an otherwise stressful exam.

We have tried to avoid the use of jargon as much as possible. However, in the interests of space we have used a number of abbreviations, and we have listed these in the abbreviations section at the back of the book.

Medicine is famous for the number of mnemonics that students have developed over the years to remember certain aspects of history or management, and we have given these as appropriate throughout the book. Memorizing the most important of these should prove useful in situations where you need to think on your feet.

No book of this nature can ever be “complete.” We encourage you to draw from other sources in preparing for your clinical skills exam. In particular, you should be familiar with advanced lifesaving (ALS) protocols, and should review general textbooks in each of the areas in which you will be tested.

Approach to clinical stations at the exam

At the exam, you will encounter clinical stations. Each will have a simulated patient and an examiner. Some stations—those about trauma or cardiac emergencies, for example—may also have a “helper” present such as a nurse.

In general you should ignore the examiner unless they specifically address you.

You should be dressed professionally and you should act professionally. Introduce yourself to the simulated patient and shake their hand if appropriate. If you are asked to perform a physical examination, ask the simulated patient for permission before you start.

Remember that, in a clinical examination like you are facing, the cases you are given to work through will be diagnosable. The examiners will not be trying to trick you. Therefore, if you are handed an ECG to interpret, the diagnosis will likely be straightforward. Furthermore, if you are asked to manage the patient based on the ECG findings, the diagnosis will likely be something that has an advanced life-saving algorithm like an acute myocardial infarction or ventricular fibrillation. Likewise, a lateral C-spine X-ray will be far more likely to show a fracture-dislocation than a rare congenital malformation; a chest X-ray will more likely show a tension pneumothorax than nonspecific findings. You get the picture.

Because the clinical stations aim to test you on relatively common, diagnosable entities, at least some of the examiners’ questions are predictable. While this book does not contain all possible scenarios, experience has shown that many stations at the exam will be similar to the scenarios described here.

Unfamiliar scenarios

If you are presented with an unfamiliar scenario, don’t panic! Even if you are completely lost, you can still often salvage a station by introducing yourself, acting professionally, performing a history of the presenting complaint, and reviewing symptoms, medications, allergies, family history, and social history. In doing so, you will likely uncover the information that will help you regroup and still do well. If all else fails, ask open-ended questions, such as “Is there anything else you want to tell me?” If you completely flop on a station, regroup and carry on for the next one.

A note on the scenarios

This book unpacks 133 cases organized around the major themes of the Canadian MCCQE II. These themes are logical and the cases are typical—they are on-point preparation for any clinical skills exam. Note that the cases are representative of cases encountered on the Canadian MCCQE II and the Certification Examination in Family Medicine in Canada, but are not direct “remembrances.”

General approaches to history taking

History taking is key to many stations in clinical exams, and so to many cases in this book. We present some general strategies for history taking below.

In all cases, it’s useful to begin history taking with a quick explanation to the patient, such as “I’m going to ask some questions to get some background information on your health and medical history.”

Generally, you should begin with questions about the present illness and then move to past medical history.

HISTORY OF PRESENT ILLNESS

Why are you here today?
When did this symptom/problem start?

FOR PAIN

What is the location?
What kind of pain is it (sharp, dull, throbbing)?
How bad is the pain on a scale of 1 (low) to 10 (high)?
Where does the pain radiate?
When did the pain begin?
What makes the pain worse? What makes it better?
Do you have other symptoms with the pain (e.g., nausea)?

PAST MEDICAL HISTORY

Ask questions to ascertain details about the following areas (mnemonic: PAM HUGS FOSS).

Previous presence of the symptom, previous conditions
Allergies
Medicines
Hospitalizations
Urinary changes
Gastrointestinal complains
Sleep pattern
Family history
OB/GYN history
Sexual history
Social history

Note that we describe specific aspects of this sequence in more detail below.

ALLERGY AND MEDICINES HISTORY

What prescription medication do you take? How long and what dosage?
What over-the-counter medications or preparations do you take? How long and what dosage?
Do you have any drug allergies? What was the reaction?
Do you have any nondrug allergies (e.g., food, environmental)? Do you carry an EpiPen?

FAMILY HISTORY

Is there a family history of diabetes?
Is there a family history of high blood pressure?
Is there a family history of heart problems?
Is there a family history of seizures?
Do other diseases run in your family?

OBSTETRICAL/GYNECOLOGICAL HISTORY

It’s wise to approach obstetrical and gynecological history taking with particular sensitivity: patients may feel embarrassed.

GYNECOLOGICAL HISTORY

How old were you when you had your first period? (Or—as appropriate—when your breasts began to develop?)
How long is your usual cycle? How many days of bleeding are usual for you?
How many pads or tampons do you usually use per day? Are there clots?
Has there been a change in the timing of your cycle?
Do you use birth control pills or hormone replacement therapy?
Have you had a Pap smear before? What were the results of past Pap smears?
What gynecological procedures have you had (e.g., loop electrosurgical excision procedure, hysterectomy)?
Have you had any STDs?

OBSTETRICAL HISTORY

Have you ever been pregnant? If so, how many times?
Have you miscarried? If so, at what stage of pregnancy?
Did you have any problems getting pregnant? Did you use any conception aids?
How many children do you have?
Were there any precipitous deliveries?
Were there any complications in pregnancy (e.g., hypertension, diabetes)?
For each child:
- What was the method of delivery?
- What was the gestational age of the baby?
- What was the baby’s birth weight?

SOCIAL HISTORY

What are your living arrangements?
What is your marriage history, family situation?
Do you drink alcohol? How much, how often?
Do you smoke?
Do you use recreational drugs?

PEDIATRIC HISTORY

Keep in mind that, in pediatric cases, patients often don’t speak for themselves, or may not speak with clarity.

MATERNAL HEALTH

How is your health today?
How was your health during your pregnancy?
How did the delivery go?
Do you have any concerns about bonding with your baby?

BABY/YOUNG CHILD’s HEALTH

How was your baby’s health after the delivery?
What was your baby’s birth weight?
What is your method of feeding your baby and how has that been going?
Has your baby had jaundice?
What are your baby’s stools like?
How often does your baby have a wet diaper?

ALL CHILDREN’s HEALTH

Do you give your child any supplements (vitamin K, iron) or medications?
Does your child have any allergies that you know of?
Are your child’s immunizations up to date?
What is your child’s diet like?
What is your child’s sleep cycle?
What activities does your child enjoy?
Do you have any concerns about your child in the following areas?
- gross motor or fine motor development
- vision, hearing
- expressive language, comprehension
- social skills, behavior

Remarks from the Launch of Committed to the Sane Asylum

Edward Day Gallery, Toronto, Canada, January 21, 2009

Susan Schellenberg and Rosemary Barnes

Susan: Hello, Im Susan Schellenberg.

Rosemary: I'm Rosemary Barnes.

Susan: Once, a long time ago, Susan exhibited her art at Women's College Hospital as part of an event honouring the December 6, 1989 massacre of women in Montreal. Susan asked Rosemary to read over the wall text which described her experiences of healing from mental illness. Rosemary said to Susan,

Rosemary: “What you've written is very interesting, but it's way too long. You should make it shorter for the exhibit and write a book. ” Then, so long ago that no one can remember exactly when it occurred, Susan asked Rosemary,

Susan: “Do you want to write a book with me?” Rosemary said yes. Susan gave Rosemary Conversations Before the End of Time, an art history book of conversations that asked, “What, given state of the planet should art be at the end of the millennium?” The book inspired Susan and Rosemary to include in their book conversations about mental health care with Susan's experiences as the case history.

Rosemary: Conversations with mental health professionals, feminists, artists and a business woman would explain diverse perspectives on mental health as the 1990s came to an end and the new millennium approached. A book would be easy, completed within six months. In 1996, psychiatrist Dr. Mary Seeman, psychologist Dr. Brenda Toner, sociologist and nurse Dr. Marg Malone, artist Paul Hogan, storyteller the late Helen Porter and businesswoman and sociologist Dr. Gail Regan all gave hours of their time for conversations.

Susan: Transcripts were prepared and these people again gave generously of their time to review and revise these transcripts. A manuscript was prepared, a publisher sought and after many inquiries, a press agreed to review the manuscript. Reviewers—unknown to Susan and Rosemary and unavailable to be thanked publically—made excellent, and positive suggestions for changes, while the press decided it was not the best kind of book for their marketing abilities.

Rosemary: Susan and Rosemary were discouraged, but revised the manuscript. In 1998, Susan's Shedding Skins art was installed as a permanent exhibit in the lobby of the Centre for Addiction and Mental Health, Clarke site. Jean Simpson, Chief Operating Officer at the Centre, and Dr. Paul Garfinkel, President of the Centre and Chair of Psychiatry at the University of Toronto, greatly encouraged both Susan's art instillation and the joint book project.

Susan: New insights and further revisions called for an additional conversation with psychiatrist Dr. Cheryl Rowe. Friends and colleagues were asked to discuss the project or—a big favour—to read and comment on the manuscript. Maureen Edgar, Dr. Sarah Maddocks, Dr. Gail Regan and Dr. Cheryl Rowe all read the entire manuscript and suggested changes. Their generosity and encouragement lifted Rosemary and Susan's flagging spirits and inspired further revisions. In 2000, Susan Macphail, Louise Fagan and Elaine Pollett of the Women's Mental Health Action and Research Coalition arranged for Susan and Rosemary to give a presentation in London, Ontario. The audience's standing ovation offered enormous encouragement. Subsequent invitations from Brian McKinnon at Alternatives Mental Health Services, Dr. Anne Oakley at the Women's College Hospital Brief Psychotherapy Centre for Women and Dr. Arpita Biswas at the Toronto East Counselling and Support Services made further presentations possible and provided valuable feedback.

Rosemary: Letters of inquiry, proposals and occasionally boxes of manuscript flew out to publishers, agents, well-placed contacts. People listened and read, made supportive comments and explained, “unfortunately, we cannot proceed with this project”. Something was wrong. More specific inquiries uncovered that the manuscript, while promising, was still a “mess” as one professional artist informed Susan and Rosemary while speaking words of great kindness and strongly urging them to continue. A search was begun for a professional editor. Author Eve Zaremba suggested artist and filmmaker Lynn Fernie, who suggested Pedlar Press publisher Beth Follett who suggested editor and poet Jacqueline Larson.

Susan: Jacqueline Larson read the manuscript, conveyed that she understood what Susan and Rosemary were trying to do and agreed to take on the project. Rosemary, Jacqueline and Susan met for ginger tea and desserts at Susan's home. Jacqueline's comments were homeopathic. Evenings of delightful conversations, great encouragement and critiques so small, precise and gently delivered that you'd wonder if anything had happened. These evenings transformed the manuscript “mess” into a suitable submission.

Rosemary: Jacqueline helped Rosemary and Susan to submit to the Wilfrid Laurier University Press, where Acquisitions Editor Lisa Quinn and two further reviewers—again unknown to Susan and Rosemary—made further excellent suggestions for changes and agreed that the manuscript should be published. Lisa and marketing specialist Leslie Macredie helped Rosemary and Susan to feel welcome at the Press and to conclude a contract for publication. Jacqueline edited the final manuscript. Chris Hoy and David Schellenberg designed a striking cover, Dr. Mary Seeman provided a strong jacket endorsement.

Susan: Nancy Webb did proofreading with a fine-toothed comb. And so the story came to an end as Managing Editor Rob Kohlmeier and other staff at the Wilfrid Laurier University Press transformed this complex manuscript with multiple voices, clinical records and art reproductions, into a beautifully designed and easily readable book.

Rosemary: This book was published in the cold of early December 2008 and tonight is being launched. We'd like to thank Leslie Macredie and Clare Hitchens for their help with marketing; Susan's nephew has already found Committed to the Sane Asylum at a bookstore in Winnipeg. We'd like to thank Mary Sue Rankin, owner of the Edward Day Gallery, for providing this beautiful space, Chris Hoy and David Schellenberg for producing the lovely electronic and print invitations to this event and Kelly, Brett and Vincent for their assistance with arrangements today and tonight.

Susan: We hope you will join us in thanking the renowned Toronto Jazz bassist Rob Clutton for tonights music. [pause] Many of you are friends, colleagues and family who have been important in our lives for many years. We thank all of you for coming and for all your support, sometimes unknowingly, for this project.

Rosemary: We'd now like to read briefly from the Introduction to Committed to the Sane Asylum.

Susan:

“There will be a place for Susan after the war, Mrs. Regan, ” was the doctor's response when my mother asked if something could be done about my artistic nature. It was 1939, I was five and the Second World War had just begun. Armed with my father's promise that a day would come when pictures of war would no longer be on the front pages of newspapers, I settled into dreaming as I waited for war to end.

Close to VE day, I dreamed a marriage between two fish. The fish dressed in traditional human wedding attire sailed off to their honeymoon in a seahorse-drawn carriage. My grade five teacher and mother, disturbed by the excellence of my fish composition, jointly concluded that despite my effort, a sixty rather than one hundred percent grade would better serve the taming of my imagination and good of my soul.

There was no let up in my Irish Catholic grooming. While the seeds of the Vietnam war were being sown and the Korean and Cold wars were raging, I trained as a nurse, travelled the obligatory three months in Europe, then broke with the Regan tradition of marrying Irish by falling in love with a first generation German Canadian. While my husband worked at excelling in business, I gave birth to the first four of our five children in four years, helped nurse my ill and dying parents and gave my all to being a glamorous corporate wife. Though exhausted, I blossomed.

In 1969, as an estimated 1 million Americans across the US participated in anti-Vietnam War demonstrations, protest rallies and peace vigils, I too began to protest but my demonstrations took the form of a psychosis.

I was solely treated with prescribed anti-psychotic drugs during my three-week stay in Toronto's, Lakeshore Psychiatric and for the ten years that followed. My former husband and I understood psychiatrists had explained my illness as schizophrenia. My willingness to take the drugs was influenced by a nursing background that taught schizophrenia was a chronic, irreversible, degenerative illness controlled solely by drugs and by my four small children's need of a well mother. Additional reasons for my drug taking included the mirroring of graphic and disturbing extremes in schizophrenic behaviours that I witnessed during my nursing career as well as during my stay at Lakeshore Psychiatric Hospital, the lack of any other explanation or meaning about my diagnosis being given to me by my caregivers, and my willingness to place sole authority for my health in doctors' hands. The combined effect of these motivating factors contributed to my certainty that I suffered from a chronic illness with no hope for recovery.

Ten years later, while Quebec was considering a split from the rest of Canada, I too threatened to split apart. My suicidal urges triggered by anti-psychotic drug side effects began to manifest and accelerate. On one of the darkest days in that period, the smallest of acts that suffice to say here represented my first ever act in my own best interests, led me to find a psychiatrist willing to supervise my withdrawal from the drugs. Soon after my decision to withdraw from drugs, I made deep commitments to heal my mind from the causes of my psychosis, heal my body from the drug side effects and to paint a record of my dreams as my mind and body healed.

Rosemary:

Healing was never mentioned when I began training as a clinical psychologist, about seven years after Susan was hospitalized with a psychotic break. Though my graduate studies in psychology had prepared me to become a university professor, scarce employment opportunities forced a career change. In September 1976, I began a post-doctoral fellowship in clinical psychology at a prestigious university-affiliated psychiatric hospital, an apprenticeship of the kind undertaken by students in every health profession both then and now.

Had any one mentioned “healing”, which few did in mental health settings, I would have considered the word flowery, quaint or quirky with connotations of primitive or marginal beliefs and practices, as in “faith healing”. Had I been challenged, I would have argued that patients improved, so clinical practices must be healing; a poetic word such as “healing” was simply inappropriate in a scientifically grounded professional setting. I would not have recognized clinical constructs and terminology to be obscuring lacunae in theory and practice.

In 1969, as Susan protested through psychosis, I protested by falling in love with one woman, then another. As I had grown up in a conservative religious American family, I understood these experiences to be equivalent to mental illness and deeply shameful. By 1976, I reluctantly reconciled myself to the conclusion that such feelings meant I was lesbian. I met other lesbians and gay men in the 1970s ferment of the gay liberation and feminist movements. Lesbian-feminist groups, new friendships and the electric creativity of the day allowed me for the first time to locate myself with confidence in the larger world. Feminist ideas infused my life with new meanings and possibilities. I learned feminist and anti-psychiatry critiques of mental health care and resolved to do be a better professional than those I read about.

For some years, I had a professional career that I understood and enjoyed. After postdoctoral training, I worked for nine years as staff psychologist at a university-affiliated general hospital and matured as a clinician and researcher. In 1986, I moved to a smaller general hospital as head of the psychology department and moved to address the split between my personal and professional lives by joining a small informal group of hospital professionals working to nurture feminist values in health care. I met Susan when she and I worked in the same political faction during the turbulence surrounding a proposed merger between the small hospital and a larger health care facility.

Then, I became lost. My ability to live with the split between feminist values and professional career commitments eroded as I became increasingly unconvinced that hospital mental health care gave paramount concern to human well-being. I felt cynical, exhausted and angry about my apparently successful career.

Susan and Rosemary:

When experiencing unbearable despair, we, Susan and Rosemary, first with wordless groping, later with increasing clarity, committed to live differently, to engage in a creative undertaking. We turned within and examined our lives to locate our most deepest values, then worked to honour these values in our day-to-day thinking, relationships and activities. We came to prize living “with an eye to delight”. We focused, to put it in health care lingo, on well being and quality of life.

If the shift to valuing pleasure sounds oh-so-lovely (cue sunshine, birds chirping, soft music), please excuse us for being completely misleading. Read on and you will find that we both moved in desperation across dark and terrifying landscapes, certain only that we could not go on as we had before. We will tell of inching along shadowy precipices of fear and doubt, harrowing encounters with outer and inner critics, lonely nights in moonless landscapes, painful deaths of false selves and other trials too terrible and numerous to mention just yet. .. .

We met in the context of local hospital politics, a kind of war zone, have worked together as friends and never been in a doctor/patient relationship. However, our ability to learn from one another, to collaborate, to nurture each other, to appreciate strengths and to balance weaknesses is an example of the honest, mutually respectful, interdependent relationship we see as essential to healing and well being.

We hope that this book shows in practice what we deeply believe, that emotional disturbance—and who among us has not experienced this in some form?—can be best addressed by living with an eye to delight and commitment to the creative, relational, earthy process of healing.