LONG CASE OSCE

OSCE PREFINAL MBBS EXAMINATION

Case:

http://108koushikchandrarachuri.blogspot.com/2023/12/long-case.html

OSCE QUESTIONS

1. Indications of CABG

• Left main disease greater than 50%
• Three-vessel coronary artery disease of greater than 70% with or without proximal LAD involvement
• Two-vessel disease: LAD plus one other major artery
• One or more significant stenosis greater than 70% in a patient with significant anginal symptoms despite maximal medical therapy
• One vessel disease greater than 70% in a survivor of sudden cardiac death with ischemia-related ventricular tachycardia

2.What are the different nerve fibres and their susceptibility to damage based on different factors?

Reference: DR.AK JAIN Textbook of Physiology VOLUME 1 

3.Primary  PCI and PCI VS CABG and medical therapy

Reference from:

https://www.ncbi.nlm.nih.gov/books/NBK556123/

• Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators
• STEMI and ischemic symptoms of less than 12 hours' duration
• STEMI and ischemic symptoms of less than 12 hours' duration and contraindications to fibrinolytic therapy

Reference from:

https://www.ncbi.nlm.nih.gov/books/NBK556123/

Percutaneous coronary intervention is being used extensively over the last many years. 80% of PCI is being done with stents. Over the past 20 years, short-term mortality, MI, and target vessel revascularization have shown a significant reduction in patients with PCI. 

Comparing the outcomes in different trials for PCI vs. CABG and medical therapy, the following are the preferred treatments for different patient categories. SYNTAX score is a tool used to estimate the complexity of coronary lesions and helps determine the decision-making process between PCI or CABG.

PCI vs. CABG

• CABG is preferred in patients with two or three-vessel disease.
• CABG is also preferred in patients with the left main disease or one or two-vessel disease and low SYNTAX score.
• CABG has shown better outcomes with multivessel disease in patients with diabetes compared with PCI

PCI vs. Medical Therapy

• Medical therapy with high-dose statins is preferred over balloon angioplasty in patients with mild anginal symptoms.
• PCI is preferred over medical therapy if the patient has;
  • Severe symptoms
  • Failed medical therapy
  • High-risk coronary anatomy
  • Worsening LV function

4.How vaccum assisted closure is useful?

Reference from:

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/vacuumassisted-closure-of-a-wound

The gases in the air around us put pressure on the surface of our bodies. A wound vacuum device removes this pressure over the area of the wound. This can help a wound heal in several ways. It can gently pull fluid from the wound over time. This can reduce swelling, and may help clean the wound and remove bacteria. A wound VAC also helps pull the edges of the wound together. And it may stimulate the growth of new tissue that helps the wound close.

A wound vacuum system has several parts. A foam or gauze dressing is put directly on the wound. An adhesive film covers and seals the dressing and wound. A drainage tube leads from under the adhesive film and connects to a portable vacuum pump. This pump removes air pressure over the wound. It may does this either constantly. Or it may do it in cycles.

The dressing is changed every 24 to 72 hours. 

Uses:

Draining excess fluid from the wound

Reducing swelling

Reducing bacteria in the wound

Keeping your wound moist and warm

Helping draw together wound edges

Increasing blood flow to your wound

Decreasing redness and swelling (inflammation)

5) Role of adipokines in CAD

Reference from:

https://www.sciencedirect.com/science/article/pii/S0939475322004653#:~:text=Adipose%20tissue%20is%20considered%20as,coronary%20artery%20disease%20(CAD).

Above picture states role of inflammasomes as a link between obesity related complications and adiposity.

Learning points from my case discussion:

1)I learned to differentiate between primary and secondary percutaneous coronary intervention based on initiation time and fibrinolytic therapy.

2)Various genetic inheritences like polygenic inheritance,autosomal dominant and xlinked dominant and if there is any genetic susceptibility of CAD in patient

3)Indications of CABG

4)Demonstration and interpretation of  joint position sense in diabetic neuropathy patient.

5)Which nerve fibres are early affected and which sensations are lost in diabetic neuropathy and leprosy cases.

6)Use of vaccum assisted closure in management of ulceration and wound.

7) Role of adipokines in cad