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Wednesday

O&G Exam

I am finally home, Alhamdulillah, Alhamdulilllah, Alhamdulillah :) Planning to be a fulltime housewife today, doing some baking and err.. err :p Exam was ok I guess, the theory part was not that bad, so was the clinical. But I really hate OSCE, we were not given enough time to write! 2 minutes for each station, and the questions were ample :( We got a laparoscopic pic of polycystic ovary, a BhCG chart for a patient with molar disease, an ampoule of MgSO4, A fetal simulator of breech presentation, and a ventouse cup. As for the PMP, it was a case of grandmultip (eh ye ke?? x ingt plak), with pregnancy induced hypertension, delivery complicated with post partum hemorrhage. The second, which was gynae case, was a bit horror. A 23 year old medical student, fainting spell during teaching with severe abdominal pain :p. Differentials?? I should have put 1. Hot ward 2. prolonged standing + skip breakfast. But it was actually a case of left tubal cyst torsion. But the final trigger was a bit out of track
1. Why do you think contraceptive pill is not suitable for this patient?
-compliance?? ada kaitan dgn cyst ke??
2. What is the most suitable type of contraceptive pill for her?? (pulak dah)
Pastu end up with DVT, dahla healthy 23 years old..haisyy

As for the clinical, I started with long case which was presented to Dr Roszaman (I got him for my short case during third year, a case of breech), 42 years old G9P7+1, underlying Gestational Diabetes Mellitus under diet control, diagnosed at 12 weeks period of amenorrhea. Last child birth 1.5 years ago. Other problems: advanced maternal age, grandmultiparity, poor spacing, failed contraception (she took Noriday, but 1 missed pill led to this pregnancy). Patient in active phase of labour.

Discussion was on
1. Do you agree with the Dx GDM?
No. It was diagnosed at 12 weeks POA, it might be DM complicating pregnancy
2. Did you look into this matter?
Yes, but patient did not do any DM screening before pregnancy, and she had no symptoms to suggest DM prior to this pregnancy

Then the discussion was on scan such as:
Do you think this patient need a detailed scan? I said yes. Organogenesis is at 7-12 weeks, and she was Dx w GDM at 12 weeks, meaning her blood sugar was not controlled duirng organogenesis, predisposing to fetal anomalies. However her sugar level was not high, around 5.6-6 only. In view of her advanced maternal age, it is important to screen condition such as Down syndrome. When should it be done? Around 18 to 20 weeks POA.

Next, I was asked about symptoms of DM. Patient had bilateral feet tingling sensation, resolved. She also had polydypsia, polyuria, nocturia developed at 7 months POA, but I said that is debatable with symptom of pregnancy in 3rd trimester.

Dr: Where do you look for ifxn in this type of patient?
Me: at the back.. (blank... terfikir pasal carbuncle)
Dr: what????
Me: oh, below the breast, groin, axilla

Dr: what do you think of her sugar control?
Me: I think it is suboptimal, as pt claim there is usually 1 high reading at each BSP. she was also not started on insulin, BSP done fortnightly
Dr: Are you sure? Cuba tengok ni (sambil menunjukkan BSP record in her antenatal book). 2 red readings for each BSP, and sometimes 3!!!!
Me: Huh????
Dr: Do o think she needs insulin?
Me: yes, because there are many red readings..
Dr: tapi you tgk value ni.. do you still think she needs insulin? (Dr dah hint2 hehe)
Me: No, the value is not that high..
Dr: Ok

Do you think she needs induction
Me: Yyess... (mcm tak brp sure nape tnye soalan cmtu huuu). It's the practice to not allow a GDM under diet to exceed EDD
Dr: I know it's the practice..but do you personally think she needs it??
Me: (err patient dahla mcm sihat je huu). Yes. Because she has high risk to have intrauterine death

Banyak lagi discussion sebenarnya, tp yg paling terkantoi habesssss: on types of induction huuu. kantoi that I didn't read on PGE1, PGE2, PGEF..last2 Dr ajar balik haha. They are different in term of potency.. He asked me what are you afraid of, to induce her with PGE? Me: uterine rupture.
Dr: tell me other types of induction that you know (ni paling memang takleh jawab). i just answered mechanical such as S&S, PGE and oxytocin. tak ingt langsung pasal foley catheter (dahla terang2 tergantung label 'foley catheter' kat katil patient huu), laminara..

That ends my long case.

Then I was waiting for my shortcase, while listening to shuhaib telling me about his long case. I was just saying, taknakla shortcase gynae, leceh kena check macam2 huu when Dr Khaled walked into the ward, smiling (I always like Dr Khaled, he is so humble and smiles all the time :), and he doesn't shout- for sure huu)
"U guys dah habis exam ke?"
"Dah habis long case"
"So waiting for short case? camne td?"
"Emm ntahlah hehe. Bolehla kot nak pass..Tapi tak distinction la"
Suddenly the sister who assisted the exam approached us. "You dah siap? La kenapa tak tunggu kat luar?" I said yes, I went outside earlier but there was nobody, so i sat at the counter, chatted with the HO, asking her what cases do we have in the ward haha. Ada breech? ada twin? semua pun takde..
Then the sister told shuhaib to go out, and asked me to follow Dr Khalid (Me: Yippeeeeeee alhamdulillah :D), while the Dr searched for the appointed patient. First, it's Dr khalid, second, it's another obstetric case! I got obstetric cases for long and short cases in my 3rd year, and both obs cases for my 5th year :p

The patient was a young 17 year old married pakistani (i seriously think she's beautiful), on blood transfusion. Was asked to describe (I said the patient was on blood transfusion packed cell O negative). So I said O-ve is usually for emergency transfusion.. but the Dr said..in the ward?? I said no.. actually the patient's blood type was really O negative huu. Discussion was mainly on causes, investigations and management of anemia. Tapi blur je.. Dr banyak bg hint huu. yang paling best, he asked, "Look at the abdomen, do you think she's term?"
I answered "NO" then siap sambung lagi..."I think she's 25 to 26 weeks pregnant" Dr Khalid appeared very satisfied. yang sebenarnya, I looked at her abdominal size was just about my abdominal size haha and I'm 26 weeks pregnant :p aci tak??

I guess that's all for the exam :D

4 comments:

Qarnikuri said...

Nice!!! hanya pregnant lady memahami pregnant lady yg lain..

'atiqah said...

tahniah dah habis final. selamat berehat =)

Ummu Iffah said...

Waah, sgt smooth session long case akak ngan dr roszaman...biasanya semua org mcm nak terkantoi je ngan dia..tp yg akak ni lain la sy rasa...

Ummu Ameer said...

@ Qarnikuri: tu ternasib baik je sama gestational age :D
@'atiqah: goodluck for final tiqah! huhuu maryam nak start posting baru dah, malasnye :( tak puas pun cuti...
@ummu iffah: haa jangan tertipu hehe. takdela smooth, cuma maybe bila tak tahu, akak straightforward ckp tak tahu... cam pasal induction tu. Dr awal akak cakap, akak biasa nampak dalam ward S&S, PGE or takpun pitocin. yg lain sume tak tahu huu. Dia ulang2 kali tanya "Betul u tak tahu?" akak yakin je angguk n mengaku haha.tp Dr Roszaman memang suka tanya as if apa yg kita cakap tak betul, tp sebenarnya dia just nak tahu whether kita tahu knp kita ckp certain things...