OSCE QUESTIONS

 60 year old female who came with complaints of shortness of breath which were intermittent and increased since the last 2 months after clinical examination was diagnosed with acute exacerbation of bronchial asthma 

1. Cardiac Asthma : 

In a case which may present as intermittent shortness of breath can also be a case of cardiac asthma and clinical examination should be done to differentiate cardiac asthma from bronchial asthma

Cardiac asthma is not a true form of asthma; it is a manifestation of congestive heart failure. It results from the accumulation of fluid in the lungs due to impaired cardiac function.

The differentiating factor of bronchial asthma is it's intermittent nature. 

2. Action of Biguanides: 

3. Role of adipokines in Insulin resistance: 

Adipose tissue acts as an endocrine organ to secrete 'adipokines' and works with the liver and brain to maintain an energy hemostasis. 

These adipokines have varying effects—some exhibit anti-inflammatory properties, while others contribute to harmful inflammation.

They exacerbate inflammation, insulin resistance, and glucose/insulin metabolism in adipose tissues and other peripheral tissues such as the liver, muscle, pancreas, and blood vessels. In particular, FABP, ASP, RBP4, and lipocalin-2 are correlated with inflammation, obesity, and insulin resistance.

Source : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617388/

OSCE points and questions common for all that all must be prepared to answer in their patients:

Q: 

What bothers your patient the most and what are his active concerns? 

List the problems in your patient in order of patient priorities and requirements 

A: 

1. The most debilitating part about the patients illness is her inability to eat and sleep peacefully. The constant shortness of breath was not only a physical challenge but also worrisome for her mentally.

2. After which her ability to take care of herself is affected. She has mentioned that she needs to people to take her to the bathroom. 

3.Her ability to do household chores is affected. She is also not able to take care of and cook for her son and daughter in law. 

Q: 

Sequence of events :

What was your patient's hourly workflow before the illness and how did it change after? 

A: 

Before the Illness:

1. Morning Routine:

   - Woke up at 6 AM and engaged in household activities, including dishwashing and cooking breakfast.

   - Breakfast comprised rice and curry, followed by cleaning the house and socializing with neighbors.

2. Daytime Activities:

   - Lunch around 2 PM, followed by cleaning and preparing food for son and daughter-in-law upon their return from work.

   - Quality family time in the evening, dinner at 8 PM, and sound sleep by 9 or 10 PM.

3. Sleep Quality:

   - Enjoyed a restful sleep, waking up refreshed in the morning.

After the Illness:

1. Altered Wake-up Time:

   - Wakes up 2 hours later at 8 AM and struggles with reduced energy levels.

2. Limited Physical Activity:

   - Inability to perform household chores due to exertion, struggles with standing for prolonged periods.

   - Reduced food intake, with difficulty in managing daily tasks and taking care of family.

3. Progressive Decline:

   - Gradual deterioration, leading to dependence on assistance for basic activities, including using the washroom.

   - Nighttime disturbances, waking up multiple times due to cough, resulting in morning sluggishness

4. Impact on Sleep Quality:

   - Sleep quality deteriorated post-illness, marked by disruptions during the night and a less refreshed feeling upon waking up. 

Q: 

What are the current diagnostic and therapeutic gaps and what more can the treating team do to fill those gaps?

A: 

 1. Telemedicine and Remote Monitoring:

 Utilizing telemedicine for regular check-ins and remote monitoring devices to track respiratory parameters. 

This can improve patient compliance, facilitate early intervention, and reduce the need for in person hospital visits.

2. Gaps in Patient Education and Self-Management: 

- We should patient education on recognising asthma triggers, importance of lifestyle modifications and the importance of adherence to the prescribed treatment plan. 

- Education regarding obesity and it's relation to CAD, DM2 and metabolic syndrome. Also teaching them regarding a balanced diet and the need for taking walks, getting aerobic activity everyday. 

3. Diagnosis of an SOB case : 

- A  thorough examination of respiratory and CVS examination to be done. 

4. Updating ourselves to the new GINA guidelines for the management of Bronchial Asthma. 

Some updates include : -

-  avoiding excess use of SABAs 

- new 'tracks' for management of Adolescent and Adult asthma 

- taking into consideration modifiable risk factors. 

Source : 

https://respiratory.medicinetoday.com.au/rmt/2023/september/feature-article/gina-2023-report-whats-new-asthma-management