Prefinal OSCE

 🍁Greetings to one and all going through my E log!!  

🩺This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment. 

I am Nomika Alli (Roll no 179) of 9th Sem MBBS. 

Here I state the questions we discussed during our prefinal and my learning based on them:

First off a brief History

A 67 year old Male came to the casualty with complaints of Shortness of breath since 10 days and pedal & facial  edema since 8 days 

Patient  came in drowsy but arousable state to the casualty . He was apparently asymptomatic 10 days back , then he developed Shortness of breath which is insidious in onset, gradually progressive in nature, aggravating on exertion and relieved on taking rest, progressed from grade II to grade III- IV (Modified MRC) 

Orthopnea, Paroxysmal nocturnal dyspnea present. 

C/O Bilateral pedal edema below knees , facial puffiness and periorbital edema since 8 days , insidious onset, gradually progressive in nature , no diurnal variation, pitting type I.

C/o decreased urine output and decreased appetite since 5days 

No C/o chest pain, palpitations, profuse sweating,

No c/o fever, cold, cough, nausea, vomiting, loose stools

Past history: K/c/o asthma since 10yrs -on medication

K/C/O HTN 6 yrs ago and used medication for 3 yrs and stopped as BP was under control

H/O TB 30 yrs ago

And hence after a series of investigations 

Diagnosis: 

UREMIC ENCEPHALOPATHY 

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD

Question 1. How did you rule out lung related disorders?

The triad of lung rel. problems: Shortness of breath, cough, wheeze

From the above symptoms, the pt. only had SOB grade II- III ( which is not exceptional to lung)

No cough and no wheeze and no sputum

 No c/o unexplained wt.loss, no chest pain

no clubbing

Question 2 . Signs of Lung congestion

SOB after mild physical activity, fatigue, rapid breathing, tachycardia, orthopnea(can occur in cvs too): all these are not exceptional to lung problems

no chest discomfort, cough, wheeze 

 

Question 3. Heart failure signs and symptoms

Increased JVP, Crepitations, tachycardia, displaced apex beat, muscle wasting

Question 4 . SOB grading

Question 5.  preload and afterload

Drugs reducing preload: ACE, ARB, diuretics, nitrates, morphine

drugs reducing afterload: ACE, ARB, alpha 1 blockers, alpha 2 agonists, labetalol, nitrates

Question 6. Hemodialysis indications

• Acute kidney injury
• Uremic encephalopathy
• Pericarditis
• Life-threatening hyperkalemia
• Refractory acidosis
• Hypervolemia causing end-organ complications (e.g., pulmonary edema)
• Failure to thrive and malnutrition
• Peripheral neuropathy
• Intractable gastrointestinal symptoms
• Asymptomatic patients with a GFR of 5 to 9 mL/min/1.73 m²
• Any toxic ingestion

reference: https://www.ncbi.nlm.nih.gov/books/NBK563296/

Question 7.  common Changes in ECGs after dialysis?

decrease in T wave amplitude and increase in Tmax time, an increase of QRS amplitude , shortened or prolonged QTc interval and ischemic-like ST-T changes

reference: https://pubmed.ncbi.nlm.nih.gov/1402512/

Question 8 . What may be the drugs given for asthma in the other hospital? Is there any risk for CKD?

Patients with bronchial asthma may have increased risk of developing chronic kidney disease. The use of steroids or non-steroidal drugs in the treatment of asthma may attenuate this risk

reference: https://pubmed.ncbi.nlm.nih.gov/24885269/

Question 9.Does bronchial asthma constitute a risk for the development of CKD? What are the factors associated with the development of CKD among asthmatic patients?

GFR was significantly lower in asthmatic and development of CKD was higher among asthmatic patients. Asthma is a type of chronic airway inflammation and proinflammatory cytokines have been shown to play a central role in the pathogenesis of asthma. The inflammation extends systemically. Studies have shown increased levels of biomarkers of systemic inflammation (C-reactive protein and interleukin-6) in asthmatic groups

This systemic inflammation could have a significant effect on initiating and aggravating other disease processes, including kidney disease, in which the cytokines and inflammatory mediators associated with asthma play a modifying role in renal disease.

Tumor necrosis factor-α (TNF-α), a mediator of the acute-phase reaction of early inflammatory response, is considered to be a multifunctional cytokine involved in airway inflammation and also increases airway contractility in asthma In the kidney, TNF-α contributes to the chronic inflammation that often precedes interstitial matrix deposition and is also implicated in obstruction-induced renal injury . Serum levels of TNF-α have been shown to be elevated in patients with CKD, with a general increase with declining renal function 

reference: https://journals.lww.com/aamj/fulltext/2017/15010/is_bronchial_asthma_a_risk_factor_for_chronic.6.aspx

Question 10. Can TB remain dormant and affect later?

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9491794/

Problems problem list:

Learning points:

• I was able to translate the theory part into real life practical part 
• I understood the importance of past history in diagnosing cases 
• I was able to build a rapo with the patient and attender helping me getting more clear detailed history (understood the role of communication)
• Understood the role of empathy in medical field 
• Computer technology has been helping a lot in this field day by day 
• I got to know about PEEP