OSCE and learning points

 OSCE questions and answers: 

1. What is steroid induced Diabetes Mellitus? 

Steroid-induced diabetes mellitus is defined as an abnormal increase in blood glucose associated with the use of glucocorticoids in a patient with or without a prior history of diabetes mellitus. The criteria for diagnosing diabetes by the American Diabetes Association is an 8 h fasting blood glucose ≥ 7.0 mmol/L (126 mg/dL), 2 h post 75 g oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L (200 mg/dL), HbA1c ≥ 6.5% or in patients with symptoms of hyperglycemic, a random plasma glucose of ≥ 11.1 mmol/L (200 mg/dL).

2. Cushing Syndrome and Diabetes II-

Cushing's syndrome is commonly complicated with an impairment of glucose metabolism, which is often clinically manifested as diabetes mellitus. The development of diabetes mellitus in Cushing's syndrome is both a direct and indirect consequence of glucocorticoid excess. Indeed, glucocorticoid excess induces a stimulation of gluconeogenesis in the liver as well as an inhibition of insulin sensitivity both in the liver and in the skeletal muscles, which represent the most important sites responsible for glucose metabolism. In particular, glucocorticoid excess stimulates the expression of several key enzymes involved in the process of gluconeogenesis, with a consequent increase of glucose production, and induces an impairment of insulin sensitivity either directly by interfering with the insulin receptor signaling pathway or indirectly, through the stimulation of lipolysis and proteolysis and the consequent increase of fatty acids and amino acids, which contribute to the development of insulin resistance. Moreover, the peculiar distribution of adipose tissue throughout the body, with the predominance of visceral adipose tissue, significantly contributes to the worsening of insulin resistance and the development of a metabolic syndrome, which participates in the occurrence and maintenance of the impairment of glucose tolerance. Finally, glucocorticoid excess is able to impair insulin secretion as well as act at the level of the pancreatic beta cells, where it inhibits different steps of the insulin secretion process. This phenomenon is probably responsible for the passage from an impairment of glucose tolerance to an overt diabetes mellitus in susceptible patients with Cushing's syndrome.

Learning points: 

- I learnt how to clinically differentiate between Diabetes I and II, MODY and juvenile type of diabetes 

-  difference between osteoarthritis and rheumatoid arthritis 

- complications of dengue

- learnt about ventilation perfusion ratio and how it gets affected in different lung conditions. 

- importance of holisitic approach and understanding

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A 77F came to the ophthalmology opd with chief complain of diminished vision

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 A 77 year old female, a housewife by occupation came to the ophthalmology opd with chief complaints of diminision of vision in the right eye since 6 months. She was referred from Ophthalmology due to uncontrolled blood sugar levels while evaluating her for cataract surgery. 

History of presenting illness: 

Patient was apparently asymptomatic 1 year back when she had nocturia due to which she went to the hospital and was diagnosed with diabetes for which she was medication. She takes Glimeperide 1mg and Metformin 500mg daily ever since. 

Patient has itchy skin lesion over left foot since one year. She also complains of itching over genitals since one year. 

She developed diminished vision 6 months back which is insidious in onset, gradual in progression. h/o lacrimation and itching. Not associated with redness. 

Past history : 

Known case of hypertension since 1 year and on medication 

Not a known case of TB, asthma, epilepsy

Personal history : 

Mixed diet

Appetite is reduced 

Normal bowel and bladder movements 

Sleep is adequate 

No Addictions 

Daily routine : 

Before 

She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, she goes and sits at a shop beside the house and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she has dinner and sleeps at 10:00 pm. 

Now 

She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, takes medication. She goes and sits at the shop and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she will have dinner and sleep at 10:00 pm. 

There is no change in the routine of the patient except for medication for diabetes and hypertension being taken regularly. 

Family history: 

Not significant 

General examination 

Patient was conscious ,coherent and well oriented to time and place.

Patient was moderately built and nourished 

Vitals

BP 140/90 mm of Hg

Pulse 80beats /min

Temperature afebrile

Respiratory rate  16 cycles/min

No pallor, icterus, cyanosis, clubbing, lymphadenopathy 

Eye: 

Right eye 

Diminised vision 

Ocular movements are not limited 

                              Right eye                         Left eye

Visual acuity         Counting fingers, 2m       6/60

Lids                       normal                             normal

Conjunctiva           Muddy                             Muddy

Cornea                  nasal pterygium              nasal pterygium

Anterior chamber  PACD = 1/2 CT               PACD = 1/2 CT

Iris                        

Pupil                   normal size, reactive     normal size, reactive

Lens                   IMSC grade I - II                

Skin Examination: 

single well defined

Silvery white plaque noted over the left foot 

Systemic examination:

CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard

P/A- 

scaphoid abdomen 

non tender, no palpable mass

bowel sounds heard 

Provisional Diagnosis:  Metabolic Syndrome 

Investigations: 

Treatment History: 

1. tab. LOSARTAN 40 mg 
   
2. Injection Human Actrapid 10 IU given before each meal 
3. Inj. NPH 8 IU twice daily