Soal OSCE Allergy 2008 Final

CASE OF ALLERGY IMMUNOLOGYYou are a resident of otolaryngology in the out patient of Otolaryngology Department.

A previously healthy 12 years boy (Ahmad M), brought by his mother to the allergy clinic with a chief complain of a frequent onset of a runny nose > 4 days and > 4 weeks.

Please analyze this case !

GUIDING FOR TUTORS

History Taking :

The student should ask further history taking according to this condition bellow.His mother notices sneezing and nasal obstruction, since he was 4 years old. Those complains were accompanied by multiple rashes of his face, feet, trunk and that as the runny nose worsened, he would have a heavy breathe and wheeze, especially on expiration. He gave a history of itchiness on wearing a nylon sock. His family history revealed an intermittent asthma on both parents and an unexplained urticaria (his sister and mother.Score about

1. Nasal obstruction 2. Problem caused at school 3. Sneezing

4. Abnormal Sleep5. Nasal itching

6. Rash 7. Family history8. Rhinosinusitis

9. Asthma10. Previous treatment

If No = 0; Yes = 1Maximal score : 10 (The mark : 100)

Pass score : 6 conditions above should be asked by the student plus one

(The mark : 70)

Fail score : less than 6 conditions above asked by the student (The mark : < 70)

What will you do after history taking ?The student should perform physical examination PHYSICAL EXAMINATION OF THE ALLERGIC PATIENT1. Examination of the face skin a. Adenoid facies

b. Allergic salute

c. Allergic shiners

d. Dennies line

2. Examination of the ear

External otitis

3. Examination of the nose

a. Nasal creaseb. Rhinoscopy anterior: inferior turbinate edema, pale, bluish mucosac. Nasoendoscopy: enlarge inferior and middle turbinate, pale, bluish mucosa4. Oral cavity/oropharynx

a. High-arched palate

b. Posterior pharyngeal wall coblestoning5. Larynx

Edema arytenoids6. Neck

Eczema

If No = 0; Yes = 1

Maximal score : 10 (The mark : 100)

Pass score : 6 conditions above should be asked by the student plus one

(The mark : 70)

Fail score : less than 6 conditions above asked by the student (The mark : < 70)

What will you do after physical examination ?

DIAGNOSIS TESTING

Skin prick tests

Puncture tests

Intradermal test

Skin end point titration test

Nasal challenge tests Ig E total

Ig E specific in serum

Nasal scraping cytology

Nasal biopsy

Nasal swab

If No = 0; Yes = 1

Maximal score : 10 (The mark : 100)

Pass score : 6 conditions above should be asked by the student plus one

(The mark : 70)

Fail score : less than 6 conditions above asked by the student (The mark : < 70)

WHAT SHOULD DO YOU PERFORM SKIN PRICK TEST Testing is done to confirm a diagnosis based on symptoms

It is usually performed on the upper back and/or on the inner surface of the lower arm Avoid exercise before allergy testing

The peak reaction usually occurs within 15 to 20 minutes and will be read at this point

The skin reaction clears quickly

Avoid antihistamines 48 to 72 hours before the test or as instructed

You may need to stop taking other medicines before testing If you have itching after the test, contact your healthcare provider for a course of action

What will you do after Skin Testing ?

The result of Skin Prick Test

0 Buffer

+3 Histamine

+3 House dust mite

+2 Cockroach

+2 Dog dander

+2 Aspergilus Fumigatus

+2 Bermuda grass

+2 Cat dander

-

If No = 0; Yes = 1

Maximal score : 10 (The mark : 100)

Pass score : 6 conditions above should be asked by the student plus one

(The mark : 70)

Fail score : less than 6 conditions above asked by the student (The mark : < 70)

1. Identify the problems!

The problems are: - runny nose,

sneezing

and nasal obstruction,

rashes of his face, feet and trunk.

a heavy breathe and wheeze

-

2. Generate hypotheses list and state the rationale for each problem!

Allergic Rhinitis co-morbidiy and complication

Multiple organ manifestation of Atopic syndrome

3. Prioritize your list hypotheses.

4. What further information do you need to prove or disprove the hypothesis.

( Please give students further information from page 2)

GUIDING QUESTIONS FOR TUTORS:

1. What is the definition of allergic rhinitis

2. Specify the immunopathogenesis of allergic rhinitis,

a. Sensitization phase

b. Immediate reaction

c. Recruitment phase

d. Late-phase response

3. What is the co-morbidity and complication

4. Describe the symptoms of allergic rhinitis, co-morbidity and complication

What is the pathogenesis of runny nose, sneezing, nasal obstruction.

5. What is the differential diagnosis

6. What is the ancillary examination to exclude the differential diagnosis?

7. What is the immunopathogenesis of sinusitis

8. What are the management of allergic rhinitis; based on immunopathogenesis

TUTORIAL I: CASE OF AHMAD M( page 2 )

His mother notices that as the runny nose worsened, he would have a heavy breathe and wheeze, especially on expiration, after take a shower with cold water.

General condition

Consciousness: compos mentis

Vital signs: Blood pressure 110/70 mmHg, Pulse 80 bpm, regular, Respiratory rate: 20X/mnt, Temperature: 36,5 0C. Body weight 40 kg. Height 150 cm.

Physical examination within normal limits

QUESTIONS:

5. How does this change your ideas about Ahmad M?

-runny nose worsened, he would have a heavy breathe and wheeze, especially on expiration.

6. What other precipitation of allergic rhinitis?

7. What further information do you need?

GUIDING QUESTIONS FOR TUTORS:

9. Specify the immunopathogenesis of allergic rhinitis, co-morbidity and complication

10. . What is the definition co-morbidity and complication?

End of tutorial 1

TUTORIAL II: CASE OF AHMAD M(page3)

The result of Prick test is positive 3( +++) to house dust mite and positive 3( +++) to cockroach positive 3( +++)

Laboratory finding :

Hemoglobin within normal limits

WBC and diff. Count

Radiological finding: revealed opacification on the paranasal sinus especially maxillaries and ethmoid lowers lateral.

QUESTIONS

7. How do the laboratory finding change your idea about Ahmad M?

8 Interpretation about the laboratory finding

9. What further information do you need to prove or disprove your hypothesis ?

GUIDING QUESTION FOR TUTORS

11. What is the meaning Hemoglobin and WBC within normal limits?

12. What is the meaning of radiological finding ?

13. What is prick test?

14. How to do prick test ?

15. What is the working diagnosis (How to take conclusion from the result) ?

Prick test : Antigen placed on the skin (volar) prior to prick , skin is tenten up with skin prich devices then prick , reaction are determined after 15 minutes .

End of tutorial II

TUTORIAL III CASE OF AHMAD M (page4)

Ahmad M was treated streroid nasal spray , antihistamine daily for 14 days and decongestant pseudoephidrine 60 mg twice a day for one week . He should to control regularly.

GUIDING QUESTIONS FOR TUTOR:

16 What is the management of this case?

- General treatment?

- Topical treatment?

- Systemic treatment?

17 . What is the prognosis of this case?

EPILOGUE

Two month after Ahmad M took steroid nasal spray , antihistamine and pseudoephedrine, he feels improvement.

=End of case=

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