Page 21 of 22

IM28.1-26 | Obstructive Airway Diseases — Assignment

CLINICAL SCENARIO

This assignment asks you to produce a structured clinical case report based on a patient with obstructive airway disease (asthma or COPD) that you have encountered during your General Medicine posting. If direct patient contact is not yet available, use the clinical vignette provided in Section 1 scaffolding. The report covers full clinical evaluation, investigation interpretation, guideline-based management planning for both stable disease and acute exacerbation, and patient-centred communication including inhaler technique counselling. You will demonstrate constructive alignment between your history, examination findings, investigation results, and therapeutic plan.

Instructions

Write a structured clinical case report using the six sections provided. Use precise clinical language with named drug classes, guideline criteria, and spirometric values. Where you refer to guidelines, name the system used (GINA, GOLD, BTS). Do not copy SDL text verbatim — synthesise and apply clinical reasoning. Word limit: 1,200–1,600 words. Adhere to the scaffolding word guidance for each section.

Length: 1,200–1,600 words across all sections

What to Submit

Section 1: Clinical History and Differential Diagnosis

Guidance: Present the history of your patient with suspected OAD. Use a structured format: presenting complaint; history of presenting illness (onset, pattern, diurnal variation, triggers, symptom-free intervals, prior episodes); relevant past medical, family, and drug history; social history including smoking (state pack-years), occupational history, and housing conditions; and a review of systems for atopic features. If you do not have a direct patient, use this vignette: Mr Rajan, 58 years, retired brick-kiln worker, 30 pack-year smoker, presents with 4 years of progressive exertional dyspnoea and productive cough. At the end of your history, state your differential diagnosis in priority order (minimum 3 diagnoses) with one positive feature supporting and one feature arguing against each. Approximately 300 words.

Section 2: Examination Findings and Investigation Interpretation

Guidance: Document the systematic respiratory examination findings expected or observed for your diagnosis (inspection, palpation, percussion, auscultation). Then interpret the following investigation results in the context of your case: (a) Post-bronchodilator spirometry: FEV1 1.3 L (45% predicted), FVC 2.8 L, FEV1/FVC 0.46. (b) ABG on room air: pH 7.36, PaCO2 5.6 kPa, PaO2 8.1 kPa, SpO2 91%, HCO3 23 mmol/L. (c) PEFR personal best 320 L/min, today 190 L/min. (d) CXR: hyperinflated lung fields, flattened diaphragms, no consolidation. For each investigation: state the key abnormality, apply the correct classification (GOLD grade or GINA severity, acid-base type, PEFR zone), and explain what it tells you about the patient's current state. Approximately 350 words.

Section 3: Management Plan for Stable Disease

Guidance: Based on your investigation interpretation, develop a guideline-concordant management plan for the stable phase. State explicitly: (a) the GINA step or GOLD group your patient is in; (b) the first-line maintenance pharmacotherapy with drug class, generic name, device type, and rationale; (c) any add-on therapy needed (LABA, LAMA, ICS, LTRA) with reasoning; (d) vaccination recommendations (influenza, pneumococcal — state doses and schedule); (e) smoking cessation — apply the 5As framework in a brief paragraph. Do not prescribe LABA monotherapy in asthma. Approximately 300 words.

Section 4: Management of Acute Exacerbation

Guidance: Your patient presents 6 months later with an acute exacerbation: SpO2 88% on air, RR 26/min, accessory muscle use, PEFR 40% personal best, temperature 38.0°C, productive cough with purulent sputum. Describe your immediate management in a numbered protocol: (1) Severity classification; (2) Oxygen prescription — state the target SpO2 and delivery device; (3) Bronchodilator regimen including drug, route, frequency, and rationale for adding ipratropium; (4) Systemic corticosteroid — dose, route, duration; (5) Antibiotic decision (indicate if warranted and first-line choice for infective AECOPD per local guidelines); (6) Escalation criteria — state clinical features that would trigger ICU referral, NIV (for COPD), or IV magnesium (for asthma). Approximately 300 words.

Section 5: Patient Communication, Inhaler Counselling, and Psychosocial Context

Guidance: Write the outline of a 10-minute clinic consultation in which you: (a) communicate the diagnosis to your patient in non-technical terms, explaining what COPD or asthma means and its expected course; (b) counsel on correct pMDI inhaler technique — describe each step in the order you would demonstrate it (at least 5 steps with the purpose of each); (c) address the impact of the diagnosis on at least two life domains (work, family, financial, psychological, social); and (d) acknowledge one specific barrier to behaviour change (smoking cessation, medication compliance, or reducing occupational exposure) with empathy and a practical strategy. Do not use jargon. Approximately 250 words.

Section 6: Reflective Integration

Guidance: Reflect on one specific moment of complexity, uncertainty, or clinical learning from authoring this case report. This might be: a point where the evidence-based guideline recommendation did not map cleanly onto the patient's individual situation; a challenge in patient communication; something you initially got wrong and then corrected; or an aspect of OAD management that surprised you. Approximately 100 words.

Grading Rubric — Obstructive Airway Disease Clinical Case Report Rubric

Criterion	Points	Full-marks descriptor
Clinical History and Differential Diagnosis (Section 1): Documents a structured OAD-relevant history with characterisation of symptoms, triggers, severity, occupational and environmental exposure, and smoking history; constructs a prioritised differential diagnosis with supporting and excluding clinical features.	15 pts	History is fully structured (onset, pattern, triggers, severity graded with MRC/CAT, occupational history, atopy, family history, smoking pack-years); differential includes ≥3 conditions with clear discriminating features for each; asthma vs COPD distinction explicitly addressed.
Examination Findings and Investigation Interpretation (Section 2): Documents a systematic respiratory examination with findings consistent with OAD; correctly interprets spirometry (FEV1/FVC ratio, % predicted, reversibility), PEFR, ABG, chest X-ray findings, and SpO2 with appropriate clinical integration.	20 pts	Examination documented systematically (inspection, palpation, percussion, auscultation); spirometric values interpreted correctly (FEV1/FVC ratio stated, GOLD/GINA criteria applied, reversibility calculated if applicable); ABG interpreted with pH, PaO2, PaCO2, and acid-base type stated; PEFR % personal best calculated; findings integrated into a coherent clinical picture.
Management Plan: Stable Disease (Section 3): Constructs a stepwise, guideline-concordant management plan for stable OAD aligned to GINA (asthma) or GOLD (COPD) framework; correctly selects bronchodilator, ICS, and add-on therapy for the stated severity; includes vaccination recommendations.	20 pts	GINA step or GOLD group explicitly stated and justified; pharmacological treatment matches guideline recommendation for stated severity; ICS/LABA/LAMA rationale explained; LABA-without-ICS in asthma correctly avoided; vaccination (influenza + pneumococcal) included; smoking cessation addressed using 5As.
Acute Exacerbation Management (Section 4): Accurately describes the immediate management of an acute exacerbation or acute severe attack of the patient's condition; correctly identifies severity, appropriate oxygen therapy, bronchodilator regimen, systemic steroids, and escalation criteria.	20 pts	Severity correctly classified (acute severe/life-threatening asthma or AECOPD severity features); controlled oxygen prescribed with correct target SpO2 (94-98% asthma; 88-92% COPD with hypercapnia risk); SABA + ipratropium + systemic steroid given; NIV criteria for COPD or IV magnesium for acute severe asthma addressed; escalation criteria (ICU/intubation) stated.
Patient Communication, Inhaler Counselling, and Psychosocial Context (Section 5): Demonstrates communication of diagnosis, management, and inhaler technique counselling; addresses the impact of OAD on work, family, and quality of life; shows empathic acknowledgement of barriers to behaviour change.	20 pts	Diagnosis communicated in patient-appropriate language; inhaler technique steps correctly described for the selected device (at least 5 steps; pMDI vs DPI distinction acknowledged); QoL impact addressed across ≥2 domains (work, family, psychological); at least one realistic barrier to behaviour change (smoking cessation, compliance, occupational exposure) acknowledged empathically with a practical strategy offered.
Reflective Integration (Section 6): Reflects on what the clinical encounter revealed about the management of OAD beyond guideline checklists — the diagnostic uncertainty, the patient's individual context, and what was learned.	5 pts	Reflection is specific and personally anchored; identifies a genuine diagnostic or therapeutic complexity encountered in this case; demonstrates understanding that guideline-based care must be adapted to individual patient context.

PEER REVIEW

Review your peer's case report using the rubric criteria. For each section, assign a score and write one specific, evidence-based comment explaining your score — do not simply repeat the rubric descriptor. Pay particular attention to: (1) In Section 3: Was LABA prescribed without ICS for an asthma patient? This is a safety error — mark down and flag it. (2) In Section 2: Has the student correctly applied the FEV1/FVC < 0.70 COPD criterion and stated the GOLD grade for the FEV1 % predicted? (3) In Section 4: Is the oxygen target SpO2 range stated? Is the choice between 94-98% and 88-92% correct for this patient? Complete your peer review within 72 hours of submission.