A 22-year-old Chinese lady who works at a kindergarten presents to you at a Klinik Kesihatan with x1/12 ho of cough. She has occassional runny nose but no fever. She has a background ho bronchial asthma since 10 years old. She is currently not on any follow up for her bronchial asthma and is on MDI salbutamol PRN.
Question 1: What relevant history would you like to know from this patient and what examinations would you like to carry out? How would you manage this patient?
Question 2: What is the level of asthma control in this lady if she admitted to have coughs every night and day for the past x1/12, takes 2 puffs of MDI salbutamol 3x/ week and easily develops shortness of breath and lethargy during work? On which treatment step is she on and how would you manage her further?
Drug Discussion: What are the mode of action and common side effects of inhaled salbutamol? What are the different types of inhaled glucocortocoids available? What are their mode of action and common side effects?
salam
ReplyDeleteansw of q1: occupation?any limitation activities?sleep disturbance?daytime symptoms?smoking? i would like to do PEF
answ of q3: uncontrolled..i think the patient should be back to step 2. treat with inhaled glucocorticoid, advice the patient on the medication, the correct technique, and patient education
answ disc: im not sure the MOA. but the common side effects are candidiasis, cough, and dysphonia.
Assalamualaikum,
ReplyDeleteThank you for your answer.
The First Step in a consultation is INTRODUCTION and OPEN QUESTION - May I know what bought you to clinic today? May I know why did you come to clinic today? How may I help you today Puan Halimah?
You should start off your history taking by asking about the acute presentation in detail (which in this case is the x1/12 cough) - duration of cough - everyday, once/ week, nightime, cough with phlegm? colour of phlegm? Haemoptysis (Red Flags)? associated symptoms (wheezing, nocturnal/ early morning cough,fever, runny nose, chest pain, SOB, orthopnea, PND, night sweats, weight loss,loss of appetite, TB contact, PMHx of pTB, FHx of lung CA, ear discharge, headache,dyspepsia symptoms, Precipitating factors (e.g.: dust, cold drinks), relieving factors (e.g. MDI salbutamol) -->
ReplyDeleteBasically what you are doing is taking history using the Murtagh Model and Hypothetical Reductive Reasoning Model whereby you are trying to exclude all the differential diagnosis of prolonged cough from the most serious ones (Lung CA, pTB) to the least serious ones (URTI)and at the end come up with the most probable diagnosis. In order to do this systematically, you need to rememberise all the causes of prolonged cough as in the Murtagh and how to exclude each one of them. This is an example of how you should arrange your thinking:
1)This patient has bronchial asthma, hence I would like to exclude AEBA by asking:PMHx of BA, FHx of BA,cough a/w wheezing and SOB, cough ppted by cold, dust, URTI sx, food, stress or excessive activities, cough relieved by inhalers and nebulizers,nocturnal/ early morning cough, ho atopy
2) pTB might be one of the differential diagnosis, so I would like to exclude pTB by asking: prolonged fever, night sweats, loss of weight and loss of appetite, haemoptysis, malaise,immunocompromised (HIV positive, long term steroids/ trad meds containing steroids), pTB contact, PMHx of pTB, BCG vaccination, recently been investigated for pTB (mantoux test, AFB sputum, ESR)
3) Lung CA might be one of the cause, so I would like to exclude Lung CA by asking: smoking history, FHx of Lung CA, loss of weight, loss of appetite, haemoptysis, SOB
4) Pneumonia might be one of the cause, so I would like to exclude Pneumonia by asking: Fever, chest pain, SOB
5) URTI might be one of the cause, so I would like to exclude URTI by asking: runny nose, sore throat, fever - it is important to differentiate bacteria and viral URTI (to decide whether to give antibiotics or not)
6) Dyspepsia might be one of the cause, so I would like to exclude Dyspepsia by asking: epigastric pain, retrosternal burning chest pain, worst on lying down, relieved by antacids, sitting up and drinking milk
You need to practise this and make sure you don't miss the important red flag questions. Your history will look unorganised and unstructured if you ask the presenting complaints then systemic review followed by the DH, PMH, SH, PSH, then you go back and ask more on the presenting complaints. Its best if you make sure you ask ALL the questions relevant to the presenting complaints before moving on to the systemic review, DH, SH, FH, PMH, PSH.
In primary care, the next most important thing to do is explore the patients I.C.E.
ReplyDeleteI - Do you know/ or have any ideas as to what might be the cause of the x1/12 cough
C - Is there anything in particular that you are worried about with regards to your x1/12 cough?
E - Besides getting treatment for the cough, is there anything else that you would like us to do for you today?
In Bronchial Asthma history of presenting comnplaints, it is important to use the GINA guidelines as a point of reference. The first step in GINA guideline is to classify whether the patient is in the controlled, partly controlled or uncontrolled group. The five key elements to categorise these are:
1) Daytime symptoms
2) Limitation of activities
3) Nocturnal symptoms/ awakening
4) Need for reliever/ rescue treatment
5) Lung function (PEF or FEV1)
Don't forget to ask how long the patient had asthma, make sure it is asthma and not COPD, is the patient on any regular follow up
Next is to determine on which treatment step is the patient based on the controlled/ partly controlled and uncontrolled group and also what type of medication is the patient on. Once you have determined which step of the treatment ladder, it is easy to plan whether to STEP UP or STEP DOWN.
Then move on to Systemic review - to screen for other illnesses
DH - how many inhalers, dose, compliance, side effects/ problems with the medications (allergies), SH(marital status, job, housing, family dynamics, smoking, alcohol, Drug abuse, opprtunity for health promotion by asking about diet and exercise, FH (FH of bronchial asthma,DM, HPT, Hyperlipidemia, Premature CHD - part of global CVS risk assessment), PMH (h/o hospitalisation for asthma or freq of visit to ED for BA, h/o intubation/ ICU admission for BA, other PMH), PSH
CLINICAL EXAMINATION:
ReplyDeleteIn this case of x1/12 cough the relevant examination should be done to exclude the differential diagnosis:
1) On inspection - she looks alert, pink, well hydrated, comfortable and not in distress
2) Vital signs: T, BP, RR, HR (pulse vol, Rhythm)
3) Hands (warmth, CRT), eyes (pallor, jaundice), throat, cervical LN, ear/ Nose examination
4) Lung examination (TRO pneumonia. AEBA, APO)
5) Ankle edema if you suspect LHF
6) Abdominal examination if you suspect dyspepsia
7) PEFR, ACT scoring in asthmatics
In primary care, when you are asked how do you manage this patient, the ideal answer is:
P - Pt education (always ask first what do they understand about bronchial asthma so that you know how what to explain to the patient and avoid repeating what the patient already knows)
Inform patient that you think the cause of the x1/12 cough is due to her bronchial asthma and not anything else serious. From the history, PEFR, Asthma Control Test, she is in the UNCONTROLLED category on STEP 1 (on MDI salbutamol PRN), needing a STEP UP approach by moving to STEP 2
In primary care, when you are asked how do you manage this patient, the ideal answer is:
ReplyDeleteP - Pt education (always ask first what do they understand about bronchial asthma so that you know how what to explain to the patient and avoid repeating what the patient already knows)
Inform patient that you think the cause of the x1/12 cough is due to her bronchial asthma and not anything else serious. From the history, PEFR, Asthma Control Test, she is in the UNCONTROLLED category on STEP 1 (on MDI salbutamol PRN), needing a STEP UP approach by moving to STEP 2
Educate the patient on:
1) What is the pathophysiology of bronchial asthma
2) Factors that can make the asthma worst
3) Relieving factors
4) Inhaler techniques
5) Asthma diary - keep track on the frequency of asthma attack and ppting/ relieving factors
6) Methods of monitoring the level of asthma control - PEFR, ACT scoring, symptoms
L- Life style changes
1) avoid precipitants such as cold drink or cold weather/ environment, dust, no pets
2) stop smoking
3) If you find the patients dietry and exercise is not up to standard, you can advise her on that as well as part of opportunistic health promotion
I- Investigations (B - blood, U - urine, R - radiology, O - others)
if having fever more than x3/7 you might want to do FBC TRO DF
Always justify why you want to perform an investigation
M- Medications (depends on the Final Diagnosis)
1) Inhalers based on the treatment ladder in the GINA guideline
2) Symptomatic treatment - PCM for fever and antihistamine for Runny nose
A- Appointment/ Safety Netting
1) Appointment depends on the patients condition - if uncontrolled, TCA x2/52 If controlled, TCA 3/12
2) Safety netting - Teach patient what they can do before coming to see you
- if you develop wheeze, SOB or chest tightness at home, take 2 puffs of MDI Salbutamol, if condition worsen go to the nearest hospital/ emergency dept asap
The main purpose of this exercise is to initiate discussion and revision amongst primary care medical student, so that you can share what you have learnt throughout the attachment with other colleagues. Different lecturers may teach you different things, so by sharing you can optimise your learning in primary care.
ReplyDeleteFor any questions in this blog asking on how to manage the patient, I expect you to give the relevant history, examination and appropriate management as I did above.I will assisst wherever possible.
Drug Discussion should be in the format as below:
Generic Name: Salbutamol
Mode of Action: short-acting β2-adrenergic receptor agonist
Dose:different dose orally, nebulised, inhalation, IV
Side effects:The most common side effects are of fine tremor, nervousness, headache, muscle cramps, dry mouth, and palpitation.[5] Other symptoms may be tachycardia (rapid heart rate), arrhythmias, flushing, myocardial ischemia, and disturbances of sleep and behaviour.[5] Rarely occurring, but of importance, are allergic reactions of paradoxical bronchospasm, urticaria, angioedema, hypotension, and collapse, while high doses may cause hypokalaemia (low potassium levels), especially in patients with renal failure and those on certain diuretics and xanthine derivaties.[5]
Safety in pregnancy, breastfeeding and children: - SAFE, High dose should be use with care in pregnancy and breastfeeding patients
You should take one question each to answer in depth, or may be one drug each. SO you can work together and reduce your burden in the learning process.
Remember that OSCE is only 15 minutes including reading questions. Be calm and answer questions appropriately.If the question ask you to take history and diagnose the condition, do so, if the question ask you to manage patient, manage patient accordingly. Listen to the PRIMER, sometimes they give clues as to what you should ask them.
thanks dr for the answers...but how to know the steps UP and DOWN..is it from the drug history only?
ReplyDeletei mean in this patient, she was prescribed with MDI salbutamol PRN and need to go to the step 2..
when do we give controllers or relievers?
According to the latest GINA guidelines, management in asthma is focused on what level of treatment does the patient need in order to achieve a good asthma control. This is clearly displayed in the treatment ladder in Figure 5, page 14 of the guideline.
ReplyDeletePlease refer to page 12 of the GINA guidelines: "Treating to achieve control" section for the answer. It explains very clearly the STEP UP and STEP DOWN approach and when to start relievers and preventers.
Always arrange for an appointment after starting patient on treatment or STEPPING UP or STEPPING DOWN the treatment ladder to assess patients response to treatment. If the asthma is poorly control, you might want to give x1/52 - x2/52 TCA. If asthma is well controlled, you can give x3/12 TCA and consider STEPPING DOWN to the minimal treatment level to achieve good asthma control.
ReplyDeletethanks lot dr..:)
ReplyDeleteOK no problem. Please invite your friends who are sitting for the OSCE tomorrow to go through this website. I hope it will provide some assisstance to your revision for tomorrow.
ReplyDelete