Case 2: History-taking and patient counseling
Caroline Kojack, 51 years old, presents to your office to discuss her insomnia.
IN THE NEXT 13 MINUTES:
- OBTAIN A FOCUSED AND RELEVANT HISTORY OF THE PRESENTING PROBLEM.
- ADDRESS THE PATIENT’S CONCERNS.
After the 10-minute warning signal, the examiner will ask you questions related to this patient.
GIVE ONE (1) LABEL TO THE EXAMINER.
Candidate voiceover: Hmmm…insomnia…she’s 51. Maybe a new concern. Probably menopause. That’s common. “Address the patient’s concerns” probably means I’m supposed to treat or counsel, as well. Maybe short-term anxiolytics, if she hasn’t had that already.
Candidate: Hi, I’m Dr. Lee. You must be Caroline…how do you pronounce your last name?
Patient (quiet demeanor, looks a bit depressed): Kojack.
Candidate (nodding): Kojack. And how would you like me to address you? Mrs., Miss,…?
Patient: Oh, I guess Caroline would be fine.
Candidate: OK, Caroline, great. So, can you tell me about your problem of insomnia?
Patient: I keep waking up in the middle of the night, and I can’t get back to sleep, no matter what I do. And when I finally do get back to sleep early in the morning, I sometimes sleep through my alarm.
Candidate: That must be really frustrating. Hmm…You’ve mentioned trying a few things…Like what?
Patient: I get up, maybe I read a book, I get a drink, I watch TV. None of it helps.
Candidate: Ok. And when did this start?
Patient: About 6 months ago.
Candidate: 6 months ago. Was there anything new in your life at the time…that happened?
Patient: Hmmm……like what?
Candidate: Like any new stressor? Any changes in your work situation, in your family situation?
Patient: Not that I can think of…
Candidate: And did a new health problem arise then, or did you start a new medication?
Candidate: No? Ok.
So far, this candidate is doing a very good job in this OSCE station. These are the things that he does well:
- Introduces himself
- Asks how the patient prefers to be addressed
- Asks an open-ended question
The open-ended question allows the patient to state what is uppermost in her mind. In an OSCE station, the SP is trained to divulge a certain amount of information in response to such a question. In this case, the SP gives a few pieces of information: she wakes up in the middle of the night, has tried some things to fall back to sleep with no effect, and then sleeps through the alarm.
Following this, the candidate does a number of other things that demonstrate good practice:
- Makes an empathic statement to develop a rapport with the patient early in the conversation.
- He picks up on one of the patient’s responses, that of duration, and comes up with nothing concrete. The SP here is not being difficult. Rather, she has been trained to provide more information to more persistent questioning.
Note that the candidate has not yet explored his assumptions about the possible cause of the problem, menopause. This helps to keep an open clinical mind. Let’s continue to watch this interaction.
Candidate: Ok, so nothing you can think of that changed…Let me ask you a few more questions, and see if anything applies. OK?
Candidate: You’re 51, that’s the age where many women have symptoms of menopause. Where are you with that?
Patient: Well, I had a hysterectomy 3 years ago, and they took everything out. And I’m on estrogen pills now.
Candidate: Ok, so estrogen pill.
The conversation can continue until the signal indicates that 10 minutes have passed. At that time, the examiner will ask you questions and the SP will no longer answer.
Once you have answered the examiner’s questions, you will not be able to reengage the patient, even if you have time left. Instead, you will sit quietly in the station until the final signal indicates it is time to move to the next station.
During the questioning component, you should think about your response before replying. Once you have answered a question and the examiner has moved on to the next question, you will not be able to go back to a previous question.
Examiner: What is your most likely diagnosis for this patient?
Candidate: She has a variety of symptoms including insomnia, amenorrhea, and hot flashes. Some of her symptoms make me think of a thyroid disorder, but because she seems otherwise healthy, I think that menopause is the most likely diagnosis.
Examiner: Which investigations, if any, would be indicated at this point?
Candidate: I would want to rule out a thyroid disorder so I would request a TSH. I would also want to rule out other causes of amenorrhea and would request a prolactin and FSH to confirm menopause.
THERAPEUTICS and MANAGEMENT
Examiner: The patient indicated that she is on oral estrogen. What are some of the risks related to oral estrogen?
Candidate: I know that individuals who have had a DVT before should not be on estrogen as it can increase the risk of venous thromboembolism. I think that it also increases cancer risk but I can’t recall the exact details.
Next, we will see what the oral questioning component of an OSCE station may look like. Not all stations will have questions at the end of the patient encounter as seen in the next case: