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)
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