from traumatized..

Last tuesday i just done my short case with prof Shuhaila. (this is my 2nd time with her..)

the scenario given was not too difficult. u may answer it too if u calm down and not get nervous. actually, all the short case conducted not very hard for student. maybe, because of severe palpitation some answer that u know cannot answer during that time. im very sure, u will know the answer after the short case settled.

For this post, i would like to share my experience from my short cases that i have encountered last year and this year with same examiner.

Last year scene..

A patient given LMP and i count the POA was 28 weeks. when i inspect the patient, a transverse scar noticed at the suprapubic area (that means a ceaserian scar). then i palpate the patient i noticed theres a hard rounded mass at the left lumbar region and i thought that was the fetal head. then i try to do pelvic grip and i dont find any presenting part at the pelvic area. so my conclusion it may be a transverse lie.

when i present this case to prof, she asked whether im sure or not that was transverse lie because she didnt know actually where the head is! (so, i was trapped there). then, i starting to wonder if my palpation gone wrong. she started to ask the definiton of lie and i cant answer it correctly.

after that, i was given a situation if this patient goes bleeding. so, she asked me:

Prof: what is your first diagnosis come to your mind?

Me: i think about placenta previa

Prof: do you think this patient diagnosed to have placenta previa?

at first, i didnt get it what she means...so i try to answer it(actually thats not the answer she wants).

Me:because this patient has no pain. :))

actually the answer is because we dont diagnosed a patient placenta previa before 28 weeks. we will called it low-lying placenta! haha..i forgot it at that time.

the she asked what risk factor in this patient did u see that she can get low lying placenta?

that time i was very confused. how can i know the risk from physical finding? so, i told her that i dont know..she was very upset and walk away after that. =(

so, after that last, i started to revised back my notes about placenta previa. then i know the answer was the patient has a previous scar! ohh...how come i didnt think about it???

allright..thats was my last year scene..i learned a lot from that mistakes. i try to study hard and understand from what i learned today. actually medicine is not that hard if u try to understand a process behind it. it is not about memorizing but it is about understanding. (thank God, Allah give me a chance to do medicine again and i hope i will use it wisely until the end)

so, lets continue from my 2nd short case.. u may find it different from the last year.

i was given a case of normal pregnancy. a primigravida.

first, i was given LMP and i count her EDD is on 3 September 2010. i tell prof that her EDD was on 5th syawal...hehe..luckily prof was buying that joke.

so i got her CFH at 32 weeks and singleton longitudinal lie with cephalic presentation. head 4/5 palpable not engaged.

prof: give me 3 causes why fetal head not engaged.

me: for that question, i think about what can prevent the fetal head enter the maternal pelvis. firstly, in this case, pregnancy at 32 weeks so, the fetus still premature. secondly, it must be a thing that prevent the head from engaged like placenta or fibroid.

prof: give me 1 appropriate investigation to rule out this causes

me: the answer is ultrasound. because i want to know the fetal well being, is it correspond to date. then locate the placenta. and find any abnormal mass like fibroid in the uterus.

prof: how u can find there is abnormal mass inside the uterus from physical examination

me: the answer is from CFH. if there was a additional mass in the uterus, the CFH should larger than date.

then, prof said it was finished. i startled at myself.."is it finished? and i answer all the question?" i found is not hard. u may say "of course la, u are repeat student.."but its not completely true because last year i found myself dont know anything like this even that is simple. i really learn a lot this time.

If u learn something to understand, u will find it easy and interesting. if u learn something just to pass the exam, u will not understand anything and it will be boring...

Dont Walk Away - Devotees

Don’t Walk Away - Devotees

Every little thing that you do

It will always come back to you

Think about the way that you feel

Head yourself up to your dreams

Don’t walk away yeah

Every single moment you live

It’s a joy if you believe

Give away all your fears

Wipe away all your tears

Rise yourself up to your dreams

So think of the future

As bright as the sun

And it will always be fun

You never had been to

The love in your eyes will

Get everything in your life

So don’t be afraid

Just say

Don’t walk away yeah

You’ve got the vision in mind

Say to yourself that you can

Stand up to your faith and you’ll find

That all you need is right in your hand

Don’t walk away yeah

This is one of my favourite nasheed songs. This song some how give me a strength in facing the obstacles in my life. Inspiration embraces my heart every time I listen to this song. Don't you feel the same way like me? Love this song so much.

Placenta Previa

Assalamualaikum,

For my 2nd post, i would like to tell about my teaching with Dr Nirmala last week. she give task for us to prepare 2 gynae case. so, we have decided to find 1 case for each group. then, when the teaching session start, she ask every member in what case we prepared each. of coz, i get shocked! this is miscommunication.. fortunately, i had clerked 1 gynae case last week. but, she doesnt seem so interested. instead 1 of our member was chosen bcoz her case was placenta previa. so, the discussion begins...

i dont rmember the case scenario. i give a new example..

Madam Ma 23 yo Gravida 4 para 3+1 at 32 weeks POA with 1 previous LSCS admitted for expectant management of asymptomatic placenta previa type 2 posterior. (this is the skema of presentation of placenta previa)

LMP: 23/2/2011

EDD: 30/11/2011

Q: How placenta previa is classified?

A: Type 1 (5cm from internal os) - minor

Type 2 (reach the internal os but not cover it) -have post(major) and ant(minor)

Type 3 (cover internal os asymmetrically) - major

type 4 (cover internal os symmetrically) - major

Q: What type that patient not be admitted?

A: Type 1, Type 2 anterior

Q: Why only after 28 weeks we diagnosed as PP?

A: because below 28 weeks, the lower segment of uterus is growing anteriorly and superiorly moving the placenta together. this placenta attachment does not move. but the growing lower segment of uterus make it like 'moving'

Q: What complication can get by PP?

A: fetal malpresentation, abnormal lie, antepartum hemorrhage, retained placenta, IUGR?

Q: What is the risk factor for PP in this patient?

A: 1 previous scar

Q: What has been done in the ward?

A: 1. timing if delivery

2. giving steroid - 28 - 34 weeks

-preparation for unpredictable vaginal bleeding coz by shearing effect

- 10 % PP can complicated to abruptio

3. trace blood group and cross-matched

- prepare to tansfused blood

4. ultrasound scan - abnormal placenta implantation

- placent accreta - anchoring placental villi attach to the myometrium, rather than

being contained by decidual cells

- placenta increta - chorionic villi invade the myometrium

-placenta percreta- chorionic villi penetrate to or through the uterine serosa and may invade surrounding organs

Q: How do you diagnosed placenta accreta?

A: by doppler ultrasound (wether there is blood flow to bladder.)

Q: if in case there is no doppler, what can you use? How?

A: Ultrasound - can see 'placental lakes' with lose of hypoechoic shadow between the bladder and placenta bed

Q: Why PP can get IUGR?

A: she told us to find it but i still dont get the answer...

Q: What is the purpose of repeated FBC in this patient?

A: 28 -32 weeks because to rule out hemodilution

32 weeks and above - if vaginal bleeding

Q: Principle management of PP?

A: I would like to admit her for mccafee regime

Correction of anemia by blood transfusion and hematinics (based on severity)

If there is bleeding, put her on pad chart - see warning blood

Plan for delivery at 38 weeks ( LSCS by senior surgeon) - forceps

Complete dexamethasone

IV drip - 16 and 14 size

Outpatient if PP type minor

Monitor baby - US and CTG

Blood bank and neonatalogist to be ready

Q: if patient progress to PPH after delivery, how is it managed?

A: 1. Activate red alert

2. Resuscitation (ABC)

3. Catheterization

4. volume replacement (whole blood, crystalloid, tx DIVC)

5. improve uterine tone by simabed/syntometrine/oxytocin

5. find site of bleeding - iliac artery/uterine artery - ligation

6. if still failed, hysterectomy done

Q: if patient doesnt want to be admitted, is she allowed to go home?

A: Yes, if follow below conditions:

1. she has minor PP

2. her house is 15 minutes from hospital

3. she is educated aand know how to take care of herself

4. rest and no heavy work

5. avoid SI - can induce labour

6. Someone can bring her back if bleeding occur

7. know to comeback if got warning blood

The type of anaesthesia of this patient must GA because spinal can cause hypotension. in PP surgery, there will be lots of blood loss and patent can go further hypotensive. GA is easy to control the circulation in case the surgery went complicated.

can u interpret this U/S image?

C = full bladder

D = placenta

E = placental lakes

G6PD deficiency..

Assalamualaikum

First of all, this is my new post. what i want to share is from my round today. my friend cover a bed with a patient's baby admitted for jaundice. the baby was a boy and diagnosed with G6PD deficiency. Below are the points that we all discuss during that time...really enjoy it.

Q: why only baby boy will be affected?

A: because this is sex linked inheritance. the gene is x-linked recessive. so the boy carry only one gene x and one gene y. so the percentange is 50 %. the girl only become carrier.

Q: What is the function of G6PD?

A: reduce NADP to NADPH in pentose 6 pathway. NADPH is needed for the production of gluthatione that is needed in maintain the RBC membrane from oxidant stress.

Q: Why a baby suffering from neonatal jaundice?

A: a baby with G6PD deficiency will prone to expose with oxidant material. jaundice usually appears by age 1-4 days, or slightly earlier than so-called physiologic jaundice. the RBC membrane will damage and called acute hemolysis. the unconjugated bilirubin will higher than conjugated one because the liver function of the baby cannot adapt the excess hemolysis.

Q: why we 'tahan' the baby?

A: to treat with phototeraphy. the phototeraphy will function as a second liver that help to eliminate bilirubin and to be secreted.

Q: What is the complication of neonatal jaundice? why?

A: the complication is kernicterus because the blood brain barrier (BBB) in newborns not well formed. so, the unconjugated bilirubin can passed through.

Q: so, what we do for the mother?

A: the mother will be counsel about G6PD deficiency, the nature, diets, exposures and risk of jaundice and its complication including kernicterus.

so, thats all the question has been asked by prof shuhaila and dr nasir

lets continue our discussions..

what are the lab findings that u look for?

1. feature of increase RBC breakdown - serum bilirubin, unconjugated, urinobilinogen, feacal stercobilinogen, serum haptoglobin..etc

2. feature of increase RBC production - reticulocytes, BM hyperplasia

3. feature of damaged RBC- morphology (FBP) - microspherocyte, fragments, peripheral blood film (presence of blister cell, reticulocyte, Heinz bodies.

what are principle mx?

1. avoid/stopped offending drug/element

2. treat underlying infx

3. severe anemia- blood transfusion

4. severe case of neonatal jaundice, phototeraphy and exchange transfusion is needed.

ok, thats all for today. thanks for reading..

a baby get a phototeraphy (not belong to this case ye..)

a new beginning...

This blog was created for myself. its content may not interesting. its just for rememorizing of what i learned from medical school. for those anyone who come across this blog, u guys must leave a comment. if u want to take a copy, with pleasure. this blogs content of teaching from my supervisor, interesting case, ward round, also from study group or alone. maybe right or wrong, so i hope u can correct me.

I created this blog because i want to make medical more interesting. i want to share with others from what i learned. if i keep the knowledge within me, it will never grow up. and i will forgot it someday. so i keep thinking, at last i want to make a blog. lantak la if many mistakes i will do. i still want to make something! something more different. at least i get the benefit, right?

*my grammar so bad isn't it?

ambil yg betul dan tegur yang salah...im still a student. not yet a doctor!

caution..every post will be update if it is necessary or get corrected.