OSCE PREFINAL MBBS EXAMINATION

https://107sujeethkumar.blogspot.com/2023/12/long-case-this-is-online-e-log-book-to.html

OSCE QUESTIONS

• How vaccum assisted closure is useful?

Vacuum-assisted closure (VAC) is an alternative method of wound management, which uses the negative pressure to prepare the wound for spontaneous healing or by lesser reconstructive options. Method of VAC application includes thorough debridement, adequate haemostasis and application of sterile foams dressing. A fenestrated tube is embedded in the foam and wound is sealed with adhesive tape to make it air tight. The fenestrate tube is connected to a vacuum pump with fluid collection container. The machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg. The VAC dressings are changed on 3rd day. Negative pressure therapy stabilizes the wound environment, reduces wound edema/bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis. All this improves the possibility of primary closure of wounds and reduce the need for plastic procedures. VAC therapy appears to be a simple and more effective than conventional dressings for the management of difficult wound in terms of reduction in wound volume, depth, treatment duration

Indications of VAC includes diabetic foot ulcers, bed sores, skin graft fixation, flap salvage, burns, crush injuries, sternal/abdominal wound dehiscence, fasciotomy wounds, extravasation wounds and animal bites/frostbite.

contraindicated in patients with malignant wound, untreated osteomyelitis, fistulae to organs or body cavities, presence of necrotic tissue and those with exposed arteries/nerves/anastomotic site/organs. Relative contraindications include patients with blood dyscrasias, patients on anticoagulants or with actively bleeding wounds

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739293/

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

• Reference: DR.AK JAIN Textbook of Physiology VOLUME 1 

• What is the reason  for shifting from oral hypoglycaemic drugs to insulin in patients with primary type 2 diabetes mellitus in due course of the disease?

Type 2 diabetes is a chronic disease characterized by coexisting insulin deficiency and insulin resistance, with the resultant hyperglycemia leading to micro- and macrovascular complications.

It has been estimated using the homeostasis multiple assessment (HOMA) that, at the time of diagnosis, ∼50% of pancreatic β-cell function has been lost, with almost 4% further loss of function expected per year thereafter (8,9). Therefore, type 2 diabetes is a chronic progressive disease characterized by worsening hyperglycemia and escalating deterioration in the function of pancreatic β-cells and loss of β-cell mass (10). Because of the progressive nature of the disease, an evolving treatment strategy is therefore necessary to maintain both fasting and postprandial glycemic control.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811479/#B9

Experience has shown the protective effects of insulin on beta-cell survival and function, resulting in more stable metabolic control. On the contrary, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions

https://pubmed.ncbi.nlm.nih.gov/18227473/

• Indications for CABG?

Coronary artery bypass grafting (CABG) is a major surgical operation where atheromatous blockages in a patient’s coronary arteries are bypassed with harvested venous or arterial conduits. The bypass restores blood flow to the ischemic myocardium which, in turn, restores function, viability, and relieves anginal symptoms

CABG is generally recommended when there are high-grade blockages in any of the major coronary arteries and/or percutaneous coronary intervention (PCI) has failed to clear the blockages

• 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

• 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
• role of visceral fat in causing CAD?

https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000973

LEARNING POINTS

 

• Importance and effectiveness of previous interventions in  assessing the current condition of the patient
• Role of vaccum assisted closure in management of wounds
• Importance of daily routine in identifying the etiology of disease
• Early signs of neuropathy in diabetics