NAC OSCE cheat sheet

Structure every encounter as: focused history → hypothesis-driven physical exam → prioritized differential → targeted investigations → management plan → safety net and follow-up.

Red-flag screen before any diagnosis: chest pain with diaphoresis, sudden severe headache, unilateral weakness, GI bleeding, fever with rigidity, and postpartum hemorrhage all mandate urgent escalation.

Symptom analysis uses OPQRST plus associated symptoms, prior episodes, and functional impact; quantify severity with a validated scale rather than adjectives alone.

Validate the differential by likelihood, danger, and treatability; the most likely diagnosis does not displace the most dangerous one until it is excluded.

Investigations follow a pretest-probability rule: order a test only when a positive or negative result changes management; state the expected result and the action it triggers.

Prescribing checklist: indication, dose by weight or renal function, route, frequency, duration, interactions, allergy, pregnancy status, and monitoring parameters.

Management plan tiers: resuscitate or stabilize, treat the working diagnosis, investigate unresolved uncertainty, and arrange follow-up with explicit time frames.

Closing the encounter requires a safety-net statement: exact symptoms, time frame, and where to seek care if the plan fails.

Open with an agenda-setting question and negotiate priorities; a single open-ended prompt followed by structured closed questions yields more accurate data than leading questions.

Use Ask-Tell-Ask for information delivery: elicit what the patient already knows, give a short chunk of information, then check understanding before continuing.

The SPIKES framework for breaking bad news: Setting, Perception, Invitation, Knowledge, Emotions, Strategy and summary.

Empathic responses name the emotion and its cause ("You sound worried this could be cancer") rather than offering premature reassurance or advice.

Teach-back confirms comprehension: the patient restates the plan in their own words; a correct restatement is the criterion for successful communication.

Interpreters are required when the patient's preferred language differs from the clinician's; family members, especially children, are not acceptable substitutes for consent discussions.

Shared decision-making names the options, the benefits and harms of each, the patient's values, and the agreed choice, all documented in the note.

Informed consent elements: diagnosis, nature of the proposed intervention, alternatives including no treatment, material risks, and voluntariness.

Closed-loop communication: sender names the receiver, gives a complete order, and the receiver repeats it back; the sender confirms accuracy.

SBAR handover: Situation, Background, Assessment, Recommendation - each element is stated explicitly, and read-back closes the transfer of accountability.

Role clarity at team formation reduces duplication; each member states their role and the team leader is named explicitly.

Conflict escalation ladder: direct respectful discussion, then involve the team lead, then formal channels; patient safety concerns bypass the ladder.

Speak-up tool: use a graded assertion ("I need you to confirm…") when a concern is not acknowledged after the first statement.

Discharge and transition planning requires the receiving team to acknowledge the plan and the responsible clinician for each outstanding issue.

Documentation of collaboration records who was consulted, the question asked, the advice given, and the agreed plan.

Triage prioritizes by time-critical need, not arrival order; airway, breathing, circulation, disability, and exposure outrank completeness of history.

Capacity decisions use explicit criteria: occupancy, acuity mix, and predicted flow; discharge planning begins at admission.

Quality improvement cycle: define the problem with data, identify root causes, implement one measurable change, then re-measure (Plan-Do-Study-Act).

Root cause analysis distinguishes system failures from individual error and asks why repeatedly rather than assigning blame.

Delegation is matched to competence and scope of practice; the delegating clinician retains accountability for the outcome.

Resource stewardship weighs benefit per unit cost; low-value tests are those that do not change management.

Escalation of care has a defined trigger: physiological deterioration criteria, a time threshold, or failure to respond to first-line treatment.

Screening criteria for a worthwhile program: important condition, detectable preclinical phase, acceptable test, effective early treatment, and net benefit outweighing harm.

Primary, secondary, and tertiary prevention map to avoiding disease, early detection, and reducing disability from existing disease respectively.

Social history screening covers housing, food security, income, transportation, and safety; each positive screen links to a named community resource.

Immunization status, smoking, alcohol, physical activity, diet, sexual health, and dental care are reviewed at every comprehensive assessment.

Barriers to adherence include cost, access, health literacy, and beliefs; the intervention must target the identified barrier.

Advocacy at the system level means identifying a population-level gap and proposing a concrete change to a decision-maker.

Mandatory reporting duties (child or elder maltreatment, unsafe driving, communicable disease) override confidentiality and are disclosed to the patient.

Ask a focused clinical question in PICO form: Population, Intervention, Comparator, Outcome.

Evidence hierarchy: systematic reviews and randomized trials above cohort studies, which are above case-control and case series; expert opinion is the weakest tier.

Sensitivity is the proportion of diseased patients correctly identified; specificity is the proportion of non-diseased correctly excluded.

Positive predictive value depends on prevalence; a positive result in a low-prevalence setting has a higher false-positive share.

Likelihood ratios update probability: LR+ = sensitivity / (1 − specificity); LR− = (1 − sensitivity) / specificity.

Number needed to treat = 1 / absolute risk reduction; absolute risk reduction = control event rate − treatment event rate.

Critical appraisal addresses randomization, blinding, completeness of follow-up, intention-to-treat analysis, and applicability to the patient in front of you.

Teaching a learner uses needs assessment, one or two learning objectives, demonstration, observed practice, and specific feedback.

Four ethical principles: autonomy, beneficence, non-maleficence, and justice; conflicts are resolved by weighing these explicitly.

Capacity requires understanding, appreciation, reasoning, and expression of a choice; capacity is decision-specific, not global.

A capable adult may refuse any treatment, including life-saving treatment, after informed discussion; refusal is documented without coercion.

Substitute decision-makers are ranked by jurisdiction-specific hierarchy, usually spouse or partner, then relatives, then public guardian.

Confidentiality exceptions: consent, legal obligation, serious imminent harm to self or others, and required reporting.

Boundary rules prohibit dual relationships and personal or financial involvement with patients; gifts and social media contact follow institutional policy.

Conflict of interest is disclosed and managed, not merely acknowledged; the disclosure is recorded in the clinical record.

Professionalism lapses are addressed directly and early; impairment is referred to a physician health program rather than managed informally.