PLAB 2 Case Scenario: Obstructive Sleep Apnea (OSA) in a Taxi Driver

Summary

This case involved a patient presenting with symptoms suggestive of obstructive sleep apnea (OSA), which significantly impacted their ability to work as a taxi driver. The feedback highlighted key areas for improvement in diagnosis, management, and communication.

Key Points

History Taking

• Asking about sleep quality and pattern is crucial.

• Clarify the main issue: Is it difficulty initiating sleep or frequent awakenings?

• Daytime sleepiness: A key feature of OSA.

• Snoring and gasping for air: Strong indicators of OSA.

• Impact on daily life: Work impairment, falling asleep while driving.

• Risk factors: Obesity, alcohol use, smoking.

Major Missed Elements

• Did not explore the main patient concern early enough—the patient had already mentioned falling asleep at the wheel, but this was not addressed promptly.

• Did not ask explicitly if OSA was the primary problem—the focus was too much on sleep hygiene instead.

Diagnostic Approach

• Confirm clinical suspicion of OSA:

  • Sleep study (polysomnography)

  • Epworth Sleepiness Scale (subjective measure)

  • Overnight pulse oximetry (initial screening tool)

Management Plan

1. Confirm OSA diagnosis: Refer for a sleep study.

2. CPAP therapy: First-line treatment for moderate-to-severe OSA.

3. Lifestyle modifications:

   • Weight loss (if overweight)

   • Exercise

   • Alcohol and smoking cessation

4. Positional therapy:

   • Avoid sleeping on the back.

   • Elevate the entire head end of the bed (not just with pillows, as flexion can worsen airway obstruction).

5. Mandibular advancement devices: For patients intolerant to CPAP.

6. DVLA Notification:

   • Essential for commercial drivers (e.g., taxi drivers).

   • The patient must inform the DVLA and should not drive until OSA is managed.

   • Risk of accidents and legal consequences if left unreported.

7. Social support:

   • If the patient cannot work temporarily, refer to social services for job assistance.

8. Follow-up and Safety Netting:

   • Reassess symptoms after initiating CPAP.

   • Provide leaflets and arrange a follow-up appointment.

Communication Skills

• Active listening: The patient felt unheard during the management discussion.

• Avoid dominating the conversation: Give the patient time to express concerns.

• Clarify concerns: The patient repeatedly mentioned they were falling asleep at the wheel, but this was not adequately addressed.

• Explain OSA clearly:

  • The issue is not sleep initiation but frequent awakenings due to airway obstruction.

  • Why CPAP is essential—explaining the rationale behind management helps patient compliance.

Ethical Considerations

• Patient Safety: OSA poses a significant driving hazard.

• Duty to Inform: As per DVLA guidelines, failure to notify OSA could lead to legal consequences.

• Non-maleficence: Addressing the patient’s concerns promptly prevents harm.

Exam Tips for PLAB 2

• Stay focused on the main issue—time is limited.

• Do not overemphasize sleep hygiene—it does not significantly help OSA.

• Manage time effectively—ensure all key points are covered within the 8-minute station.

• Use clear, simple explanations—avoid excessive medical jargon.

• Check patient understanding—encourage engagement in the consultation.

Final Takeaways

• OSA is an urgent issue requiring immediate action.

• Confirm diagnosis with a sleep study.

• Management should prioritize CPAP, weight loss, and positional therapy.

• Driving restrictions and DVLA notification are critical.

• Patient engagement is key—avoid one-sided discussions.