osce question
This is a case of 70 year old female who came with complaints of shortness of breath which were intermittent and increased since the last 25 days and after clinical examination was diagnosed with acute exacerbation of bronchial asthma.
Sequence of events:-
👉What was your patient's hourly workflow before the illness and how did it change after?
Before the Illness:
1. Morning Routine: The patient used to. Wake up at 6 AM
Engaged in household activities like dishwashing and cooking breakfast.
Breakfast comprised rice and curry, followed by cleaning the house and socializing with neighbors.
2. Daytime Activities:
Lunch around 1PM,
Having some sleep after lunch 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:
She used to have a peaceful sleep
After the Illness:
1. Altered Wake-up Time:
Wakes up 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 disturbanceswaking up multiple times due to cough, resulting in morning drowsiness.
4. Impact on Sleep Quality:
Sleep quality deteriorated post-illness, marked by disruptions during the night and a less refreshed feeling upon waking up.
Learning points:-
👉How do you differentiate the coarse crepitations vs fine crepitations
coarse crackles, which are loud, low pitched, and fewer in number per breath.
fine crackles, which are soft, higher pitched, and greater in number per breath.
I have learnt about the importance of detailed history taking to rule out the factors that exacerbate her symptoms.
👉How the disease affected her daily routine.
👉 pathogenesis of bronchial asthma.
Bronchoconstriction. In asthma, the dominant physiological event leading to clinical symptoms is airway narrowing and a subsequent interference with airflow. In acute exacerbations of asthma, bronchial smooth muscle contraction (bronchoconstriction) occurs quickly to narrow the airways in response to exposure to a variety of stimuli including allergens or irritants
Airway hyperresponsiveness.
The mechanisms influencing airway hyperresponsiveness are multiple and include inflammation, dysfunctional neuroregulation, and structural changes; inflammation appears to be a major factor in determining the degree of airway hyperresponsiveness.
Airway remodeling:-Airway remodeling involves an activation of many of the structural cells, with consequent permanent changes in the airway that increase airflow obstruction and airway responsiveness and render the patient less responsive to therapy .These structural changes can include thickening of the sub-basement membrane, subepithelial fibrosis, airway smooth muscle hypertrophy and hyperplasia, blood vessel proliferation and dilation, and mucous gland hyperplasia and hypersecretion .
https://www.ncbi.nlm.nih.gov/books/NBK7223/
👉 medications that we are providing to treat her symptoms.
Asthma exacerbations are a major cause of disease morbidity, increases in health care costs, and, in some patients, a greater progressive loss of lung function.The frequency of exacerbations can be reduced, but not always fully prevented, with adequate inhaled corticosteroid (ICS) treatment or combination ICS/long-acting β-agonists (LABA). Because asthma exacerbations can break through standard treatment regimens, identifying at-risk patients and having a plan of management can improve disease control and patient well-being.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950727/
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