Clinical Exam: Short Case with Prof H

Dr : This patient LMP was 27 April 2010. What is her POA & EDD?

Me: 34 weeks + 1 day POA, EDD was 3 February 2011

Dr : (Showing the red book) This is the patient past obstetric history. Summarize it

Doctor's Summary (obviously!)

In summary, the patient, G6P5 at 34 weeks with 4 living children with history of low birth weight baby and history of premature labour at 28 weeks for last child. the child died at 2 months of age. Currently came with premature labour. Examine this patient abdomen.

During examination I could not heard fetal heart upon auscultation (even after given 3 chances)

Dr : You never practice ye...(dusH! head shot..)

So basically singleton fetus with longitudinal lie, cephalic presentation, head 2/5 palpable.

Dr : If you are the houseman at screening what do you want to do.

Me: After history and physical examination, I would like to time contraction. Exclude Braxton-Hick and true premature contraction. I would like to do speculum examination to look for vulva vagina excoriation, liquor, sign of infection such as candidiasis (tembak!) and opening of os

Dr : Really candidiasis? What causes premature labour? Infective causes. (Dr must have expected me to go around the bush with all sort of answer..haha)

Me: Bacterial vaginoses, group B streptococci.....candidiasis, I'm not sure.

Dr : Candida did not cause premature contraction. How would you manage?

Me: I would like to investigate...

Dr : You haven't finish your PE. What else in vaginal examination?

Me: (Knock in the head) I would like to check for the station, cervical opening and effacement...(basically all the bishop score but couldn't remember the other 2)

Dr : OK investigation?

Me: I would like to do high vaginal swab, CTG

Dr : What other investigation? Let's say if it is available here..

Me: Fetal fibronectin

Dr : What is its significant?

Me: If positive, patient is having premature labour. (tet! wrong again...)

Dr : Basically if it is positive, patient will deliver within 1 week. Patient is been admitted, what do you do?

Me: Since patient is at 34 weeks, I would like to give 2 injections of IM dexamethasone 12mg 12 hours apart. Tocolytic agent to let the effect of dexa took place.

Dr : After tocolyse?

Me: I would monitor patient for fetal heart rate, respiratory rate & blood glucose...

Dr : Why glucose? Patient is not diabetic.... ok that all. Did you think you perform well during Long Case?

Me: I'm not sure. (Dalam hati..pasrah)

Clinical Exam: Long Case with Dr B

26 years old Malay housewife from Muadzam, primidgravida at 28 weeks POA, gestitional diabetes mellitus on diet control with acceptable glucose control and asymptomatic anemia on double hematinics (which I don't emphasize earlier during summary) came with complaint of pervaginal bleeding 2 days prior to admission.

Discussion of History

Dr: Why didn't you emphasize on complications of GDM from ultrasound? What are the complications that I want?

Me: Fetal macrosomia & polyhydramnios. I did mention in the history, the fetal growth was corresponding to the date with adequate liquor

Dr: No, you should mention it specifically in this type of cases. (One more thing is that fetal anomalies only occur in preexisting DM not GDM)

(After the history presentation, because patient remember all the details...)

Dr : Did the patient tell you all this?

Me: Yes

Dr : So what is the patient education background?

Me: Err, sorry I didn't ask....(OMG lupa la plak)

(After summary, it is as above but minus the asymptomatic anemia)

Dr : What is other problem that patient had?

Me: Oh, asymptomatic anemia...

Dr : So why didn't you said so? You should not focus on presenting complaint only...treat patient as a whole. Since patient in the low social economic group, did she had basic amenities in house? What kind of toilet that she had? How about her diet? Did you ask?

Me: Sorry Dr, no...(isk3 my social history very poor)

Dr : What is the simple investigation that you would like to do in this patient since patient had anemia?

Me: TIBC, Serum ferritin, stool ova & cyst.

Examination revealed that she was not pale. No signs of infection at the web space of hands, axilla, mouth, neck and breasts. But I didn't look for it at groin & vagina. SFH was 26 cm and clinical fundal height was corresponding to 28 weeks gestation. Fetal part felt but could not appreciate the fetal lie/poles because it is so small with relatively thick skin. (Dr said that must try to assess and find it since we're gonna be HO)

Further Discussion

Must know site of infections in GDM (as listed above)

Dr : If you are in the district what do you want to do to this patient?

Me: I would like to do ultrasound to exclude PP, if PP excluded I would like to do speculum examination.

Dr : What do you want to find?

Me: Vulva and vagina erosion, liquor, cervical erosion, growth, irregular margin. Os opening..

Dr : Do you expect any infection in this patient?

Me: No because patient had good control of glucose.

Dr : Any other specific thing in cervical that you would like to check?

Me: Oh cervical polyps (while knocking my head)

Dr : If you unable to determine what is the cause of bleeding, what is your diagnosis?

Me: Indeterminate APH

Dr : How you manage APH? When to deliver patient?

Me: Take FBC, GXM...Resus...deliver at term

Dr : When?

Me: 38 (Goreng!). I not sure.

Dr : We not allowed post date. why?

Me: Don't know. (until now haha! I'll inform later)

Dr: If patient is in premature labour, what is your management? Patient at 28 weeks. Who to inform other than specialist, consultant, nurses...

Me: (After being pushed) IM Dexamethasone, tocolysis.....(Being pushed further) inform paeds for ventilator (at first I wrongly said "incubator"...pening2)

It can be done...

"It can be done"

That what Dr Suraya said...insyaALLAH we can...

Good luck for exam everyone!

Neonatal Jaundice Predictive Value

Found this during wardround after been alerted by Dr Suhaiza...

Shiny Teeth and Me...

I found one clip from a cartoon regarding teeth care...kinda cute

take care of your teeth ok haha

Clinic Session with Dr S

Have clinic session with Dr S yesterday....totally enjoy it

34 Malay G2P1 came with uterus larger than date for assessment with history of nose bleeding in early pregnancy, whitish discharge with foul smelling & streak of greenish mucus (forgot when); completed treatment of vaginal pessary for 3 days. Upon further questioning, she had cystectomy for endometriosis 9 years ago & 1 untried uterine scar for EMLSCS due to prolong labour.

So what to highlight in history?

Causes of larger than date such as wrong date, fetus causes (big baby, multiple gestation), polyhydramnios, pelvic mass (uterus/ovarian mass)

Whitish discharge with foul smelling & streak of greenish mucus..what do likely cause?

At first, I thought it was bacterial vaginoses but it is actually candidiasis with superimposed infection because patient was treated using pessary for 3 days which most likely is Canesten pessary

Nose bleed common in pregnancy?

Yes for some because of generalised vasodilatation affecting Little's Area. (some may presented with gingivitis; also due to same causes)

Stages of endometriosis?

(anatomical staging) ---> not related to symptoms/fertility prognosis

stage 1 (minimal) - superficial lesion with filmy adhesions

stage 2 (mild) - as above plus some deep lesions in pouch of Douglas

stage 3 (moderate) - as above plus endometrioma in ovary & more adhesions

stage 4 (severe) - as above plus endometrioma with extensive adhesions

So in this patient at least stage 3

Ultrasound was done & found that normal fetus weight with normal AFI & no adnexal or uterine mass...so what happen?

Possibly of adhesion due to previous surgery that lead to upward stretching of the uterus lead to larger than date (based on SFH)

p/s: little bit sad because unable to clerk uv prolapse today because too many people have clerk it (hard-to-find admission!) and I've clerk 1 patient with PIH..after clerking the BP was 150/100 mmHg. I felt that I'm the one causing it...I did pray a lot hopefully patient did not develop pre-eclampsia/severe hypertensive crisis.

Welcome to the Family, Nur Irdina!

(Irdina=our pride/our blessing)

Nur Irdina....what a nice name for my first niece!

Ahlan wa sahlan ya Irdina.. May Allah give you blessing throughout your life as bountiful as your name. Be a pride to your parents as prideful as your name ok!

Congratulation to both Khairi & Kak Anis...may Allah bring more mawaddah wa rahmah in your family..Ameen

p/s: Sorry for not being there to support...As usual I'm "busy" with my life as medical student. Busy get scold by specialist due to my acquired bad-houseman attitude. Teruk2 (Ya Allah minta jauhlah dari sikap tak cakna ni..)

Class with Dr A

Just finish class with Dr A just now... had discussed about 2 cases. (I wrote it here because I forgot to bring my notebook during class, so I think why not share it here..haha)

First Case

25 yo Malay lady G2P1@37 weeks POA came for ELLSCS with conjoint twin. diagnosed at 21 weeks POA

Complications of twin pregnancy?

In general, all possible obstetrics complications!! So early detection of twin is needed to prepare the mother & family...(so friends try to practice scan before becoming MO ok)

Why do we need to take BP every time we clerk patient? (which most of us don't)

Because we afraid of hypertension in pregnancy more specifically pre-eclampsia & eclampsia

Why?

Because it's one of the common cause of maternal and perinatal death... then he started to take about a patient who had twin pregnancy with rapidly progressed pre-eclampsia before. Both twins died in utero while mother succumbed after 1 month staying in ICU

Second Case

18 yo unmarried G1P0@33 weeks POA came with fainting episode that associated with symptoms of anemia. She unable to tolerate oral hematinics lead to poor compliant.

Management of anemia in pregnancy other than typical oral hematinics?

Oral Obimine, IM interferon, IV Venofer (like coke) etc...transfusion is the last resort

Why do we treat anemia in pregnancy aggressively?

Because patient can develop pph, thus lead to maternal death

How to reduce bleeding during labour?

Optimise the hemoglobin level (at least 10 g/dL)

Avoid prolong labour since It could lead to pph secondary to uterine atony. (augmentation of labour if poor contraction)

Active management of 3rd stage where most common time to develop pph (syntocinon injection, control cord traction)

If patient had pph/risks to develop pph, infused 40 unit pitocin after removal of placenta

Complication of teenage pregnancy?

cephalopelvic disproportion due to undeveloped pelvis

Legal issue regarding baby from unmarried mother?

Currently, baby had to be given name with bin/binti of his/her mother...Kesian budak tu bukan dia yang salah tapi mak ayah dia. Seumur hidup la malu anak luar nikah tu dapat pada dia & semua orang tahu. Dulu bin/binti Abdullah..orang tau juga, tapi kurang la sikit stigma tu.

(personally I think this is not a good management of issue by Government)

well that are some of the things that we discussed...enjoy study ok!

ToneMatrix...amusing!

take a look...it is fun!

tonematrix

p/s: enjoy producing sound from it

Trial in Life

Allah tests his servants in different way...

Allah test one with our study....school exam, SPM...

Allah test one with pregnancy...

Allah test one with doubtful thoughts...

Even our joy is a test from Allah.

But remember Allah did not test us on something that we could not bear..

Setiap kesusahan itu, ada kesenangan...

May Allah give strengthen our iman. Ameen.

p/s:

1- Najwah good luck SPM...insyaALLAH boleh

2- Kak Anis & Khairi doa banyak2 insyaAllah selamat..

Jom Sihat

Yesterday we had our final year project at Sekolah Bukit Sagu 1. Even though we had to face many trial throughout our preparation, Alhamdulillah it ends up well. Here a some of what we had done...Credit to Ahmad Ghaus for the video. Congratz everyone for the excellent jobs!!

p/s: adam, lagu perut tu memang trademark anda...sealed!! haha

FYP Jom Sihat from ahmad ghaus on Vimeo.

Stressful Week!

what a stressful week...

entering one of the most unpleasant posting in my clinical year..O&G and yet I become the leader for the posting out of nowhere....

currently preparing for this again unwanted and burdening program...seriously, I've never join any program if I don't enjoy it...just wanted to finish this thing off. so many things to be done with so little of help...Afif be ikhlas.....Allah make me more sincere in my work

sorry..this entry just to release my stress...not to offend others

Orang Putih pun pandai berbahasa Melayu

Kadang2 aku pelik, jalan kat KL...tengok muka Melayu, kulit Melayu...tapi cakap Melayu tak tau... bila tanya, memang Melayu... isk3 malu rasanya dengan mat saleh seorang ni....

Kalau kita tak sayang bahasa kita siapa lagi kan? Aku rasa aku pandai juga bahasa Inggeris tapi tak lupa la bahasa sendiri. Apa yang aku lagi tak suka kalau orang pertikaikan kepentingan atau kelebihan bahasa Melayu. Bagi aku setiap bahasa ada keunikannya...setiap bahasa melambangkan budaya dan pemikiran si pengguna...

BAHASA JIWA BANGSA

Good Luck exam!!

hm..musim exam sekarang ni...haha aku pun exam esok. tension sekali..ok la good luck kengkawan...mcm org slalu kata, bring it on...doa byk2 moga Allah permudahkan.Amin

Budget 2011

baru habis tengok bajet 2011...perasaan? ntah la..campur2 la. Some of the things in it I agree, some don't. May be later for further comment ok...

read this and analyse yourself

Budget 2011

No More PMR...

"Kasihan cikgu..." That my first reaction towards this issue. Some people says it is good, some don't. Let's analyse this issue ok...

Pros

1. "Less exam oriented" assessment for students, which is partially true...because students still need to under gone exam, right?

2. Reduce country burden to finance for public examination. For me, it is wise enough economically but if only Government could retract the PTK examination among government servants... Well the aim of PTK exam are good theoretically but practically not useful and wasting lots of government efforts & money in order to produce highly competitive workers..

3. .... I add later if I have any?

Cons

1. Do you think that teachers had enough important & non important jobs to do....

Teach students, set exam question/exercises, mark it, write notes for students, handle students' disciplines... become a co-curiculum advisors, follow students for tournament/competition, become supervisor for landscape, supervisor for Koperasi, supervisor for canteen, printing papers, sort out papers, taking attendance & further more which I can't think of.

Why can't school become like universities where academic staffs only focus on academics while non-academic supports the management of the institution?

2. No exam, no worries, no study...But not all students are lazy like "pahat dengan penukul" right?

so you decide...is it good or not ok. Let's think it with rationale not sinister.

Anyway I would like to congratulate to all teachers for being such an extraordinary persons... without all of you there will be no doctors, lawyers, lawmakers, businessmen etc.

A Piece of Knowledge in A&E

40 years old gentleman known case of diabetes came with breathlessness. Dextrostik showed glucose was 20 mmol/L. He was initially diagnosed as diabetic ketoacidosis until ECG was done and found that he had NSTEMI (click here to read for more info regarding myocardial infarction).

Oxygen was given, sublingual GTN was given....IV morphine plus maxolon... all the emergency treatment was done...but patient restless & suddenly collapsed.

CPR was done, intubation was done & atropine with adrenaline was given but patient succumbed to the illness.

Moral of the Story

1. Myocardial infarction (MI) is a number one killer in Malaysia.

Before this accident I've never seen patient with myocardial infarction died...so I thought that may be most of them died years after having MI...come on Afif, wake up! Be more attentive & observant...another few months to go before becoming HO.

So, here some advice for all of us..watch what you eat, take care of your health... even if you have hypertension, diabetes or previous MI, never & never stop taking care of your health because it is the amanah from ALLAH

2. To all medical students, know your stuffs well before becoming doctor...!!

First & foremost your theory must be good... as our doctors always said the eyes never see what the brain never know, which is 200% true. As in this patient he had no angina pain due to his diabetes...so let us start study ok!

Secondly practice & practice all your clinical works during your study especially when it comes to resuscitation. Because when we, medical students do CPR on that day for me it was terrible especially myself. It was asynchronous & shallow in short it produce irregularly irregular rhythm...which is totally opposite to what the medical assistants did..and never hesitant to learn from anyone including your own patient.

3. A&E can be tiring & full of frustration

So be mentally prepared ok! Always remember that doctors are human..even with the best treatment, only ALLAH can save a soul. For those who aim for A&E specialist...gud luck & may ALLAH bless you.

Hope this entry benefit all of us...

Be Positive

Feeling hopeless, worthlessness...due to study? or life event?

well we should be grateful actually for being relatively normal physically/mentally compare to others.... and even the unfortunate have a fortunate life. Why not us? Watch this. Hope it will elevate our motivations.

So always & always be positive and never stop praying to ALLAH...May ALLAH give us strength & good faith.

Raya di Klate 2010

Lama tak update blog ni... almaklum la cuti raya...raya tahun ni agak special la bagi aku sebab semua adik-beradik & sepupu balik kampung...

Tahun ni la 1st time Kak Anis beraya dengan kitorang. Kak Anis mesti pening tgk ipar2 dia yang macam2 ragam... ini antara gambar2 ketika raya.

Memang kecoh dengan gelagat sorang2. Orang putih kata "a picture worth 1000 words" (haha entah betul tak, belasah...) ----> sebenarnya tak reti nak bercerita, so sebab tu aku tunjuk gambar banyak2.

ni antara gelagat yang sempat dirakam...

Ramai sepupu2 aku duduk luar klate sekarang. So anak2 diorang pun ramai yang berbahasa baku... Dalam banyak2 ni ungkapan paling best skali "jangan soyok (koyak dalam bahasa baku)..."(bayangkan perkataan ni disebut secara baku oleh budak 8 tahun, memang comel hahaha).

Yang best lagi sekarang musim buah..memang la tersangat banyak buah2 di dusun tu... habis satu bonet kereta ada buah..kenangan paling tak boleh lupa waktu ambil buah waktu kena gigit kerengga betul tak Fikri? tapi memang berbaloi hasilnya & lagi nikmat kalau kita kait sendiri..

Banyak lagi sebenarnya tapi tak berapa rajin nak edit video2 tu...
OK la...taqabballahu minna wa minkum untuk semua.. kisah raya ni ada 2nd season dia tapi kat KL pula...

Killing spree...

~ni la kartun yang paling sesuai utk soal buang bayi ni~

As you all heard/watch/read from radio/tv/newspaper regarding the inhumane killings of babies are rampaging... for me it's totally frustrating to see some people killing their own child while so many others waiting to have one. Below video from Youtube which shows animal can be merciful to others...why not us?

Ramadan Karim...

Ramadan is here...time for us to enhance our 'ibadah and good deeds... let's us reduce our bad deeds...

May ALLAH give strength & barakah for every good intentions & deeds..

here is a Quranic verse regarding Ramadan & saum. MAy ALLAH include us among them who are muttaqin

183 O ye who believe! Fasting is prescribed to you as it was prescribed to those before you, that ye may (learn) self-restraint,-

184 (Fasting) for a fixed number of days; but if any of you is ill, or on a journey, the prescribed number (should be made up) from days later. For those who can do it (with hardship), is a ransom, the feeding of one that is indigent. But he that will give more, of his own free will,- it is better for him. And it is better for you that ye fast, if ye only knew.

(AL-BAQARAH verses 183-184)

p/s: if there is any mistake, do correct me...

Selayang Elective

It's kinda weird to post this after a month since our elective in Hospital Selayang. Anyway just to share some of the memories & results of our mini research

Credit to Hafiz for the photos...

This is some of our activities in the hospital (discussion, data collecting and entry, ECG course Hepatitis Day)

And some of our extra-hospital activities...

And here is the result of our 6-weeks posting

COMMON MEDICAL PROBLEMS IN SURGICAL WARDS AND COMMON SURGICAL PROBLEMS IN MEDICAL WARDS IN HOSPITAL SELAYANG (WITH SPECIAL ATTENTION TO PRESSURE SORE) IN MAY 2010

Special thanks to Prof Kyaw, Dr Taufiq, Dr Safina, Dr Ibtisam and all that supported our posting in Hospital Selayang

From left: Hamzah, Razak, Dr Taufiq, Hafiz & me

Marshmallow Test...

I just put up this video because the children's behaviours were cute...

but there are some psychological importance..read this for further info regarding Deferred_Gratification

Final Year....

I will enter my final year as student in 4 days..insyaALLAH

It will be psychiatry posting first..hopefully it will be as thrill as 3rd year.

I wonder which books should I read? Anyone?

bola...bola...bola...

world cup dah start!!!

choose your fav team...ada yg minat team2 kuat cam brazil, spain...ada yg suka sokong pemain haha

ni 5 team yg aku suka tengok diorg main...

jepun & korea selatan - sebab semangat juang yg 200%

argentina - sebab dia main ada strategy plus samba bukan mcm brazil guna individual skill je

itali - sebab aku suka defense n counter attack dia... kuda tua pun kuda tua la..

england - sebab aku suka tradisi bola dia & diorg main ikut strategy..

anyway semua team power2 n potensi menang tu ada...

may the best win!!

kepada peminat bola jgn gaduh2 sbb jabulani tu bulat..dan jangan tuang kelas & kerja ok!

Fikri's Convocation!! (22nd May 2010)

Fikri's convocation in Shah Alam...here some pictures to share (not much of my picture since I'm the man with camera)

We queue to get to the in-campus bus (no car permitted!!)

While mama & abah go in to the hall..

we enjoy ourselves at the stall

and another stall...

It's time to eat!!

We search flower for Fikri...

and this is the result....a beautiful pink daisy (hope Fikri likes it LOL!)

so many people waiting outside

picture of a loving couple

and another loving couple

Here is our man of the day!!

family photo

family photo with me in it

ok that's all..gud luck Fikri and here some dedication for you to keep you motivated...