Topic: Woman with depression
Subject: Psychiatry
What The Candidate Reads
Candidate's Instructions

OPENING STEM: A 43-year-old woman presents with inability to sleep. She takes diphenhydramine for sleep but this has not helped.

CANDIDATE'S TASK: Hx

IN THE NEXT 13 MINUTES:
  • OBTAIN A FOCUSED AND RELEVANT HISTORY

  • After the 13-minute warning signal, the examiner will ask you to answer questions about this patient.


    PATIENT INFORMATION

    PATIENT STARTING POSITION: Sitting on a chair next to the examiner.

    CLOTHING: Wearing jeans and a sweatshirt. Wearing shoes and socks.

    MAKE-UP: Face is pale

    PATIENT'S OPENING STATEMENT: I have been having problems sleeping lately.

    PATIENT BEHAVIOR, AFFECT AND MANNERISMS: Patient stares at the floor and rarely makes eye contact.

    QUESTIONS PATIENT MUST ASK: What can I do to help my sleep?

    QUESTIONS PATIENT MAY ASK: Is what I have hereditary?

    HISTORY OF PRESENT PROBLEM: The symptoms began a few weeks after losing my mom due to cancer three months ago. It started with a loss of appetite but I thought it was just grieving. Then I couldn't sleep. It takes me an hour to fall asleep because I'm anxious when I go to bed. Even so, I wake up at 3 am and can't get back to sleep. I feel helpless and dragged out. I am tired all the time and have little or no interest in my usual activities. I think of death a lot but I have not made any plans to take my life.

    PATIENT ISSUES: She sees the situation as serious and is at her wit's end. She is not functioning in her daily life and does not want to get worse.

    RELEVANT MEDICAL HISTORY | ALLERGIES | MEDICATIONS: History of sexual abuse as a child. It was a one time thing and she had good parental support around the issue.

    RELEVANT SOCIAL / FAMILY HISTORY: She does not smoke or drink alcohol. Her father was an alcoholic and her mother suffered from depression after giving birth and during her forties.

    REVIEW OF SYSTEMS: She has vague abdominal pain after eating. Her periods are sporadic.

    PATIENT SIMULATION: Looking at floor and speaking softly and slowly.

    PHYSICAL FINDINGS: She has a hunched over posture and is picking at her nails. She has mild abdominal pain on palpation with normal bowel sounds.

    INFORMATION GIVING: Maintains poor eye contact throughout except when talking about suicide. She seems slightly angry when the topic of suicide comes up.

    PERTINENT NEGATIVES: She has not lost weight. She has not had any job-related problems.


    What the examiner completes

    EXAMINER'S CHECKLIST

    Fill in the bubble for each item completed satisfactorily
    History Taking Checklist

    1) Asks about circumstances of symptom onset  [Answer: Symptoms occurred 3 months ago when her mother died.]

    2) Asks about when the patient gets to sleep.   [Answer: I fall asleep at 10:30 pm]

    3) Asks how long it takes to get to sleep.   [Answer: It takes over an hour to fall asleep.]

    4) Asks when she wakes up.   [Answer: I wake up at 3 am and can't get back to sleep.]

    5) Asks about daytime fatigue.  [Answer: I am tired all the time.]

    6) Asks about appetite.  [Answer: My appetite is decreased.]

    7) Asks about concentration.   [Answer: I can't focus on her work.]

    8) Asks about irritability.  [Answer: I am not irritable.]

    9) Asks about anxiety.  [Answer: I feel anxious much of the time.]

    10) Asks about relationships  [Answer: I feel distant from my husband.]

    11) Asks about illicit drug use.  [Answer: I only take diphenhydramine for sleep.]

    12) Asks about prior episodes like this.   [Answer: This has not happened before.]

    13) Asks about family history of depression.  [Answer: My mother and maternal aunt had depression. ]

    14) Asks about other psychosocial changes in life  [Answer: Nothing except the loss of my mother.]

    15) Asks about body aches and pains.  [Answer: I don't have any body pain. ]

    16) Asks about self harm.   [Answer: I don't suffer from self harm.]

    17) Asks about suicidality.  [Answer: I think about death a lot.]

    18) Asks about suicidal gestures.  [Answer: I have not had any suicidal gestures]

    19) Asks about past psychological trauma.  [Answer: She was sexually assaulted at age 8.]

    SCORING TABLE

    If UNSATISFACTORY, please specify why:
    Inadequate medical knowledge and / or provided misinformation
    Could not focus in on this patient's problem
    Demonstrated poor communication and / or interpersonal skills
    Actions taken may harm this patient
    Actions taken may be imminently dangerous to this patient
    Other:
    Did this candidate demonstrate a lapse in professional behaviour? Yes No
    Disrespectful to others (e.g., to patient, nurse)
    Over-investigated / over-managed the patient
    Actions raised ethical and / or legal concern
    Briefly describe the behaviour for any of the above reasons or any other observed lapse:




    PATIENT INTERACTION RATING SCALES

    Up to a total of seven interaction items may be added to a 14-Minute Encounter Station, depending on the task that candidates are asked to complete. One or two interaction items may be added to a 6 minute case.

    Individual interaction items are weighted on their relative importance to each other for a specific station. The weight for the combined items ranges from 10% to 50% of the total score for any one station. The MCC OSCE interaction rating scales are here:

    PATIENT INTERACTION RATING SCALE ITEMS

    FOR THIS 14-MINUTE ENCOUNTER STATION, YOU MAY BE EVALUATED ON UP TO A TOTAL OF SEVEN OF THE FOLLOWING PATIENT INTERACTION ITEMS:

    6, 7, 11, 13, 16