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..)