COMMON ,IMPORTATNT OSCES for amc clinicals

Discussion in 'AMC Clinical Exam' started by OTD, Oct 10, 2007.

  1. OTD

    OTD Guest

    Bell’s Palsy

    Reassurance about stroke à Patient will feel much better
    Ask questions which help diagnosis
    - Have you been unwell?
    - Were you alright the night before?
    - Find s/s: flu?
    - Do you have DM or high blood pressure?
    - Have you had it before?
    - No need to ask stoke questions à already diagnosed
    Explain pathogenesis
    · This is Bell’s palsy, the nerve that supplies the face is paralyzed.
    · It’s self-limiting 75%, >90% recovery in 3-6 weeks

    Why it happens?
    Draw a diagram, cause is infection, autoimmune.
    Use the word ‘might have’.

    Any treatment?
    If due to HZ, give Acyclovir
    Examine the ears to see blister.
    If patient comes in 3 days à Steroid may help
    General treatment
    - Diet, water
    - Take care of face by
    · Use glasses
    · Artificial tear
    · Ointment or ABO eye drop if infection occurs
    - Refer to PT à facial exercise advice
    - Analgesic for pain

    Questions in the real exam
    Do you think it is stroke?
    Why it happens?
    Will I have it forever?
    How can I do in front of others?










    Hepatitis C

    Breaking a bad news or reassurance
    - Is it alright if I go ahead?
    - Do you want someone to stay with you?

    Ask for risk factors
    - She was an IV user à IV drug might be the cause of hepatitis C

    Management
    General
    · Notify the authority and blood bank
    · Test the partners and children
    Specific
    · Refer to gastroenterogist
    · Anti-viral treatment

    Information sheet, support group
    Ask feed back from the patient: What do you understand?
    Review the test to partner à make an appointment
    Inform that ‘You’re not able to donate blood’.
    Liver might become cirrhosis, cancer à regular blood test for LFT

    It is unlikely to transmit by sexual intercourse.
    Vertical transmission à if not sure, refer to O&G




    Herpes Zoster (Shingles)

    Questions to ask:
    - Immunosuppressive history? DM?
    - Are there any children at home? (child might get chickenpox)
    Treatment:
    · Acyclovir in 72 hours: 800 mg 5 times a day X 7 days
    · Calamine lotion or soothing lotion
    · Anti-histamine: ask for occupation, drowsy or non-drowsy drug
    · Steroid in really bad case but not proven

    Complication:
    · Post-herpatic neuralgia if last beyond 1 month à see you in 2 weeks if analgesic cannot control.
    · Herpes opthalmaticus à can cause corneal scar


    ADHD

    What’s been bothering you?
    How’s his performance at school?
    Does it happen recently? Or on going?
    How is his grade and how was before?
    Notice any changes at school? Concentration span?
    What is his relation to school mates and teacher? How about family?

    What do you do? How many children?
    How much time you spend with your kids?
    Does he sleep? (never look tired)
    FH?
    How bad was it?
    Do you drink alcohol? Smoke? Recreational drugs?

    Does he behave like this at home?
    Is anything going on at home?

    DDX: ADHD
    Conduct disorder
    Anti-social personality
    Depression (if not eating well)

    Treatment:
    · Counseling
    · Child psychiatrist
    · Imipramine (stimulant)


















    Mental State Examination (MSE)

    General appearance
    Mood: Objective
    Affect: Subjective
    Though: Delusion à Grandiosity
    Suicidal
    Perception: Hallucination
    Cognition
    Insight

    In psychiatric patient, have to exclude
    · Thyroid
    · Menopause
    Can say psychotic illness, instead of schizophrenia


    ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

    PTSD & Depression

    Always think about thyrotoxicosis and other medical conditions
    Psychiatry: Good history
    Counseling
    Differential diagnosis

    PTSD (Post-traumatic stress disorder)
    · Nightmares: Had it happened before? When?
    · Flashbacks:
    - Do you think about that quite often?
    - Have you been to the place it happened?
    - Does anything remind you of that? (trigger)

    Precipitating factor
    Trigger
    Avoidance
    S/S associated with it: Panic attack
    Impact
    a. How does it effect your social life?
    b. Personal life? Work?
    c. Relationship?
    Coping: How are you coping?
    d. Coping skill: Drug & alcohol or social support (?)
    Medical problems
    e. Do you have medical problems esp. thyroid?
    f. What do you do? Have you had any mental/emotional problem?
    g. Is there any FH of emotional problem?

    Depression questions
    · How is your mood?
    · How is your energy?
    · How is your sleep?
    · How is your appetite?

    Some people, when they go through this experience, they start drinking or use elicit drugs. Have you been using them?

    Have you had any thoughts of ending your life? (harming yourself?)
    Do you have anyone to talk about it?
    Would you like to talk to someone?
    Find whether she need psychotherapy or urgent treatment.
    **Identify risk of harming herself or others**

    Do you have a feeling of worthlessness?
    Have you been feeling guilty? Can you enjoy what you used to?

    You really need treatment at this stage.
    If suicidal idea à admit & consult psychiatrist
    If you don’t want, I have to use law.

    Be safe, non-judgment and low-tone voice
    Ask menstrual history to exclude thyroid.
  2. OTD

    OTD Guest

    Miss Howe is a 22 years old woman with two children and would like to be sterilized. Obtain informed consent for tubal sterilization.
    More history:2 children
    Partner, father of second child
    No work, partner is also unemployed
    She doesn’t like the pill

    Management
    Explore relationship: stable?
    Talk about other contraception:
    # Male sterilization: easier
    # IUD (Mirena): carry risk of infection esp. this case; more chance of having more than one partner and unstable relationship
    # Implantation: last about 3 years (Implanon)
    Explain pros and cons of sterilization
    # If fail, increase risk of ectopic pregnancy
    # reverse rate is very poor: 25-70% and still increase ectopic pregnancy after reverse
    # reverse procedure is not cover by medicare
    # long waiting list
    Explain about laparoscopy and surgery of tubal ligation
    Give another contraception before she leaves as she has to be on contraception while she is in the waiting list

    (Hello Mrs. Howe, I’m Dr……., I understand that you come to see me today because you want to do permanent sterilization. I would like to ask you a few questions and the condition related to you, is that alright?

    You are 22? Do you have children? How many? Are you sure that you don’t want to have any more children in the future?
    Do you have a partner? Does he know about your decision? Does he agree?
    Why do you want to be sterilized?

    Do you know about other contraception methods such as oral contraceptive pills, coils, condoms, diaphragm and cups? There is also an implantation for contraception that is very effective and can be used for about 3 years each time. Have you heard about that? Are you interested in considering that?

    What do you know about female sterilization?
    Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked (draw diaphragm). This stops eggs moving down to meet sperms.

    The operation can be done in several ways, the most common method is by laparoscopy or a key hold surgery. This is usually done under general anesthesia, where you will be put to sleep. A doctor will make 2 tiny cuts, one just below your nevel and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope, it is a thin telescope-like instrument with lense to look at your reproductive organs.

    Another common way is by mini-surgery, usually you will be put to sleep as well. A doctor will make a small cut in your tummy, just below the bikini line to reach the tubes.

    You need to stay in the hospital, usually a couple of days, depending on types of anesthesia and operation. After operation, if you have general anesthesia, you might feel unwell for few days and may have some bleeding and pain, which is slight.

    You must consider sterilization as permanent method of contraception. However, there is an operation to reverse it but it is complicated and may not work, Medicare doesn’t cover for that either.

    The failure rate of female sterilization is 0.1-0.3%. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy, which is very dangerous.

    The advantage is that it does not interfere with sex, your womb and ovaries will remain in place. Ovaries will still release an egg every month and your sex drive and enjoyment will not be affected. Actually, they may improve as fear of pregnancy is no more an issue. Occasionally, some women might find their period becomes heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as you feel comfortable.

    You must continue contraception until time of operation as now you are put in a waiting list. If you use IUCD, it should be left until the next period. You should contact your doctor if you think that you are pregnant or if you miss a period and especially if it is accompanied with tummy pain.)
  3. OTD

    OTD Guest

    37 years old woman is considering pregnancy in next few months. She is anxious about her risk of Down syndrome and has come to you regarding prenatal counseling. Your task is to counsel her.

    Management
    History of other risks such as DM, HT
    FH of chromosomal abnormality: Down’s syndrome, cleft lips, cleft palate
    Tell about the risk of Down’s syndrome is each age group, compared to normal population
    Prenatal screening process for down syndrome
    Risk of fetal loss during the procedure
    If test is positive, refer to genetic counseling
    Ask if the tests are positive, what is she going to do? The investigation is not covered by medicare
    Other screening for preconception: Rubella, VZ, chicken pox
    Folic acid 3 months before and after conception

    Fact about Down’s syndrome screening
    Risk of Down’s syndrome:
    Normal population 1:600-700
    30 1:350-400 35 1:250 37 1:200
    40 1:100 43 1:50
    risk of 2nd child is 1:100
    Screening test
    1. Ultrasound for nuchal fold at 11-14 wk (12, first trimester)
    2. Maternal serum test for b-hCG (­), AFP and estriol (¯) at 15 wk (second trimester): These 2 tests can detect 85-90%, false positive 1%, if both are positive, then this is high risk pregnancy, have to
    3. Amniocentesis at > 16 wk, can detect 100%, fetal loss 0.5-1 % (1:200)

    (Hello Mrs……., I’m Dr……… How are you today? As far as I know, you want to get information about risk of Down’s syndrome, is that correct? Before we get to that point, I would like to ask you some questions, related to your planned pregnancy, is that O.K?

    You are 37 years old, is this your 1st pregnancy?
    Do you have any other medical problems such as high blood pressure, diabetes?
    Is there any genetic problems in your family such as Down’s syndrome, cleft lips or cleft palate?
    What do you about Down’s syndrome?

    Down’s syndrome is a genetic disorder that associated with advanced age mothers. In general population, the risk of having a Down’s syndrome baby is 1:600-700 and increased to 1 in 100 in 40 year-old mothers. In your case, at 37, the risk is about 1 in 200. You can get pregnant even though it is a high risk pregnancy as there are screening tests to detect Down’s syndrome during early pregnancy. Do you have any idea about that?

    Firstly, we can do ultrasound to detect any abnormality in fetus in the 1st trimester and then take blood sample from you to analyze in the 2nd trimester. There are several chemistries in you blood that can be tested, if they are higher or lower than normal, it can be suspected for Down’s syndrome and some abnormalities in baby. These two screening tests can detect about 85-90%, if both tests are negative, it is less likely to have a Down baby. On the other hand, if both tests show abnormal results, you will be then put in a high risk group and need to have another test done, which is a diagnostic test with 100% accuracy to detect Down’s syndrome. It is an invasive procedure, which called “Amniocentesisâ€, have you heard about that?

    Obstetrician will put a needle through your abdomen and womb to get cells of the baby from the fluid around him or her and then analyze. By this procedure, you can know the conclusive result whether the baby has Down’s syndrome or not.

    However, this procedure might damage the fetus but the percentage is quite low, about 0.5-1%, which is 1 in 200 of fetal loss. In you case, this chance is as same as the chance of having a Down’s syndrome baby.

    If your first 2 tests are normal, it is a very good news, if not, you still have a choice to have the confirmation test or not, it is all up to you. Even if the result show abnormal gene, it is also your choice to continue your pregnancy or terminate. You have to think about these things carefully, as the test is not covered by medicare.

    Have you seen children with Down’s syndrome?
    They share similar characteristics as well as inherit from their own parents. They are likely to have other medical problems such as heart disease, hormonal disorder and might have difficulty in feeding. However they can actually live in normal environment with some super-visions and they are quite loveable, fun and enjoy music.)
  4. OTD

    OTD Guest

    A 20 years old woman who has stopped her OCP three months ago, comes with a history of irregular light period and abdominal discomfort for the last few weeks. She has come in with her partner to ED. Yours task is to access and discuss management.

    Pain comes and go at LLQ for 2-3 weeks, 2 days ago pain started to be more severe, got pain killer from GP but pain is getting worse. Slight Vg bleeding, not Vg discharge. She stopped pills as she wants to get pregnant.

    History: Hx of PID, LMP that was regular,
    Have you done a pregnancy test?
    Do you have any symptoms of pregnancy?

    PE: LLQ pain, speculum: brownish fluid, PV: os closed, tender at cervix
    Ix UPT, UA, U/S

    Ddx 1. Ectopic pregnancy
    Missed abortion (PE excluded)
    UTI
    Twist ovarian cyst
    PID
    Stop OCP
    Appendicitis (if right)

    Mx 1. Medical treatment by methotrexate and follow up
    Surgery
    Post explore lap., can’t drive for 6 weeks.

    (Hello, my name is ……., I’m a doctor for you today, what should I address you? As far as I know you have had vaginal bleeding with tummy pain. May I ask you some questions regarding to your problem? Do you want me to give you pain killer before we start?

    Can you describe the bleeding for me? Is it bright red? (MC) Or dark red or brown? (EP) Is there any clot?
    How many tampons or pads you use?
    Can you tell exactly where the pain is?
    What it feels like? Have you had the same pain before?
    Did the pain started before bleeding? (EP) or you saw bleeding then felt pain? (MC)
    What make pain better? Worse?
    Do you have other symptoms? N/V? Diarrhea? Anorexia? Vg discharge?
    How were your periods? Regular of irregular? When was you last period that was regular?
    Why do you stop pills?
    Have you done a pregnancy test? Do you think you are pregnant?
    Have you ever had ectopic pregnancy before? Any miscarriage?
    Any medical problems? Any medications?
    I would like to examine you, are you comfortable with that?

    Miss……., now, we have had a good look at you tests that we ran. And according to the results of the test, the examination and what you complained of, there is a high possibility that you have what we call “Ectopic pregnancy” that is a pregnancy outside your womb, this can be in the tubes between your womb and ovaries as in most cases or inside the tummy, which is very rare. As the pregnancy is not in the usual place, it cannot continue to term. I understand that it is very disappointing for you but this condition can be more serious as it may bleed suddenly and can be life-threatening. To avoid this, we have to admit you in the hospital and refer you to obstetrician, she or he will make a definite diagnosis by laparoscopy or key hold surgery. This is the procure by which we insert a tube with lense within a small incision in your tummy, after we put you to sleep, so we could look at your womb and tubes.

    The treatment of this condition, it can be done either by laparocopy to inject a medication (Methotrexate if sac is <3cm) or remove the pregnancy.

    Another way is by operation to remove pregnancy. Both ways of treatment, the doctor will try to preserve the tube, but if it is damaged by this condition, then the only way to deal with it is to remove the tube.

    Is everything clear? Do you want me to repeat anything for you?
    Are there any questions that you would like to ask me?
    You will remain for few days in the hospital (2-3 days).
  5. OTD

    OTD Guest

    A 19 year-old woman, 28/40 week pregnant, primigravida, found BP 170/110 mmHg and urine protein 2+ at ANC clinic. She also has frontal headache
    Task: Relevant history
    Important findings and investigation
    Management

    Diagnostic criteria
    Mild 140/90
    Severe 160/110 (6 hours apart, 2 episodes)
    Associated symptoms
    Headache
    Visual disturbance
    Nausea/vomiting
    Epigastric discomfort
    RUQ pain à liver
    Swelling
    Signs
    Hyperreflexia
    Very excitable clonus
    Edema
    Investigations
    FBE: platelet
    LFT: increase AST, ALT
    Urine protein 24 hours
    Uric acid
    Coagulation
    Urea, creatinine
    HELLP Syndrome: Hemolysis
    Elevate Liver enzyme
    Low Platelet
    Management
    · Admit to assessment unit for 2 hours
    · Bed rest and repeat BP
    · Do blood test
    · Repeat urine or start urine 24 hours
    · CTG for fetus, U/S
    If BP is still high, manage HT à Call physician to treat HT and find associated disease
    If BP is settle down around 140/90 mmHg, normal LFT, urine, platelet, and baby is o.k., still admit until collect 24 hr-urine protein
    Try not to give hydralazine in a hurry
    D/C and follow up 2-3 times/week (home visit)
    If continue HT à hydralazine à MgSO4 when impending eclampsia and then plan to delivery.
    Continue MgSO4 until 24 hours post-partum. If everything tends to be normal and urine output is good à stop
    If not, continue MgSO4 until everything tends to be normal.
  6. OTD

    OTD Guest

    young lady, experienced traumatic F/D, 2 weeks post-partum, she feels restless and down.
    Task: Management

    Ddx: Postpartum depression

    History:
    What happened during the delivery? Maybe she had bad impression about her labour, they didn’t do C/S…..Baby got bruise and mark on face.
    How is your sleeping?
    How is your appetite?
    How is your energy level?
    Do you breast feed?
    Do you feel like harming yourself or others, especially baby?

    I really sympathize with youà make her feel comfortable to talk
    Social support for taking care of baby à rest and enough time to sleep
    Find out if anyone support for finance.

    Offer psychiatric refer but need to get consent from the patient for that, if she still has insight.
    Do you like to see a specialist or you have anyone you would like me to refer you to?

    If baby is in danger, can admit the baby to health scheme and contact human service.
  7. OTD

    OTD Guest

    28 years old lady at GA 40 weeks. ANC is normal but she wants to know about labour is overdue.
    Task: Discuss management
    Counseling about prolonged pregnancy and post-term

    Findings:
    Recheck date
    CTG
    PV
    This case, CTG is done today and the result is fine, date is 40 weeks. PV shows bishop 2-3, fetal movement is 10 in 12 hours.

    Explain that it’s O.K. that the baby is overdue.
    · Only 4% deliver on due date
    · 60-80% deliver 1 week ±
    · 2-3% goes beyond 2 week (10-14 days after due date)
    However, if the pregnancy goes beyond 42 weeks, there is increase incidence of intrauterine death so we have to do CTG weekly.

    If she is extremely anxious and ¯ fetal movement:
    · CTG twice a week
    · U/S check amnio-fluid index (AFI)

    Tell the date to induce and explain about how to induce:
    · Start from Prostaglandin
    · ARM (When your cervix starts to open, we’ll break the water)
    · Oxytocin 10 unit + NSS 1000 cc start 40 drop/ hour, adjust with contraction every 5 min, until get 3-4 contraction/10 min. (We’ll give you hormone to make you start contraction, you can request epidural block if it’s too painful.)
    · If fail induction à C/S or F/E

    Complication of posterm
    · Meconium aspiration
    · Intervention labour
  8. OTD

    OTD Guest

    Primigravida, comes to you requesting C/S. Discuss pros and cons.

    Pros: ¯ incidence of urinary incontinence
    Cons:
    · Risk of anesthesia
    · 6 weeks to heal
    · ­ Risk of DVT due to immobilization
    · Risk of fail lactation
    · ­ Risk of next C/S
    · ­ Incidence of placenta previa, aruptio placenta
    · ­ Postpartum risk
    · Not good to have many children: after 4-5 children, most cases end up with hysterectomy
    · ­ Rupture in uterine segment
  9. OTD

    OTD Guest

    A pregnant lady 34/40, wants to have C/S due to husband is going overseas. Advice.

    No C/S when absent medical condition, advice seek 2nd opinion, might be OB or Paediatrician.

    I’m not happy to do it but you can seek second opinion for that
  10. OTD

    OTD Guest

    A 58 year-old woman presents with acute PV bleeding
    Task: Ddx
    Management

    The important thing to ask is she’s undergone menopause or not.
    Ddx: Malignancy (Cervix or uterus)
    Atrophic vaginitis
    Polyps
    Drugs: Warfarin
    Coagulation defect
    HRT
    Trauma: postcoital bleeding

    History:
    Pap smear: 10 years ago (stop pap smear when 65, having 2 normal pap smear in the last 5 years)
    Menopause?
    Hysterectomy?
    Medication
    Trauma, sexual intercourse

    Physical examination:
    GA
    Lymph nodes
    Abdomen: mass?
    External genitalia
    Speculum examination:
    o Get biopsy if abnormal
    o Pap smear if normal
    PV
    PR if think about cancer

    Investigation:
    Transvaginal ultrasound: ³ 4 mm
    o Small endometrial biopsy (Pipple?)
    o No need for D&C
    o Hysteroscopy and D&C if many….(?)
    § If can’t tolerate, use GA
    Important investigations:
    o Pap smear
    o U/S transvagina
    o Endometrial sample (if ³ 4 mm) à if result is negative, 95% exclude cancer

    If grade 1, refer her to Gyne-oncologist for further management, might be hysterectomy and/or radiation.
  11. OTD

    OTD Guest

    Vaginal Herpes Simplex type 2 in a pregnant woman.
    Task: Manage the case
    Addressing concerns
    (May 2005, Melbourne)

    If active lesion à C/S and when PROM < 6 hours
    If primary lesion à increase risk of fetal transmission.
    If repeated, less severe.
    Can give acyclovir, safe for fetus.

    Hepatitis B: Passive immunization at birth
    Get protected during pregnancy
    · Hepatitis immunoglobulin with Hepatitis B vaccine at birth and then at 1 and 6 months
    · Can have N/D or C/S

    Hepatitis C: If PCR is +ve, chance of vertical transmission is 5%
    If nipple is crack à no breast feeding
    If nipple is O.K. à O.K.

    HIV: 50% if N/D and mother is not treated
    25-30% if mother is not treated
    5% if mother is treated:
    · Zidovudine from 20th week then infant is also should be given.
    0.5% if mother is treated and C/S

    Genital Herpes (O&G p.141)
    Risk of transplacental transmission is 1:1000, more likely to happen in primary than recurrent infection.
    Risk is greater during childbirth, particularly if mother has developed a recurrence of the condition or is shedding the virus from her cervix.
    o A woman with a history of genital herpes need have no anxiety that her baby will be infected and may expect to be delivered vaginally, unless a recurrence of the infection or a new infection occurs during the pregnancy.
    o If a first infection or a recurrence of genital herpes occurs during the pregnancy, but has healed by the time labour starts, the woman may give birth vaginally.
    o If herpetic lesions are present when the membrane rupture or labour starts, a C/S should be performed to avoid the risk that the baby will acquire a herpetic infection during the passage through the birth canal.
    Take endocervical swab for viral culture every 2 weeks from the 34th week should be abandoned, as positive HSV-infective swabs do not predict the risk of the infant being exposed to herpes infection during birth.
    There may be a connection between genital herpes and cancer of the cervix, but that cancer is treatable if Dx early- ‘a smear a year’ is the rule.
  12. OTD

    OTD Guest

    Mastitis – tender breast 4 days after delivery
    Task: History, diagnosis and management
    (May 2005, Melbourne)

    A 30 years old female, mother of a 4 weeks old baby boy, comes to see you complaining of feeling tired, fatigue and fever with some left side breast tenderness
    Task: Take relevant history
    Ask about the examination finding from the examiner
    Discuss the diagnosis with the patient
    (Midia’s tutorial)

    PE: Temp. 38.4
    Breasts: left is erythematous, tender, nipple-OK
    Ddx: Mastitis
    Breast abscess: treatment is I&D and admit

    · Start feeding from affected side first (soft tissue injury so baby can suck from affected side) so baby sucks more
    · Don’t stop breast feeding now because it’s important to empty the breast
    · Keep breast fed for 2-3 week then if the patient wants to stop, she can
    · Treatment by ABO (Flucloxacillin) for 10 days, paracetamol, cold cabbage leaf, no need to admit
  13. OTD

    OTD Guest

    --------------------------------------------------------------------------------

    A lady who is 20 weeks pregnant, noticed yesterday that her 6 years old son has developed chickenpox rash. She is enquiring regarding her exposure to chickenpox.
    Task: Take relevant history and answer patient’s questions.
    (May 2004, Brisbane)

    If > 20 weeks, less chance to get infected.
    It is dangerous in pregnancy, complication could be even encephalitis is the baby.
    If contact early in the 1st trimester, can cause fetal anomaly.

    This case, check her serology for IgG and IgM
    If IgG is positive: no worry
    If IgG and IgM is negative: repeat in 2 weeks
    Consider give 12.5 units/kg of VZV immunoglobulin IM within 72 hour (or 7 days?) after exposure.

    O&G p.142
    · Primary infection can result in serious complication for both mother and baby as maternal immune system is less efficient.
    · Complications:
    § Pneumonia 10% in mother can lead to death
    § First trimester: fetal anomaly such as microcephaly, lung hyperplasia, cataract, IUGR, psychomotor retardation
    · If maternal infection becomes apparent 7 days before or after delivery, the baby is at risk of developing disseminated varicella infection as maternal Ab production will not yet be adequate.
    · If doubt about the Dx or previous history of infection à take blood for IgG and IgM
    · High risk: give VZV immunoglobulin IM
    · Severe maternal infection: Acyclovir 5-10 mg/kg every 8 hours.
    · Infected infant maybe given both VZIG and acyclovir

    OHCS p.216
    · If mother is affected 1 week before or 4 weeks after, the baby might get severe infection à isolate from other babies and give VZIG and acyclovir
  14. OTD

    OTD Guest

    26/40 week pregnant is present for her regular check-up. Two weeks ago FH was 26 and now is 40 cm. No complaints, she is Rh+, GTT normal, U/S at 18 weeks was normal. The U/S is done today. There is a large amount of amniotic fluid and something wrong with the baby (?). I admitted because she lived 30 km from the hospital. The patient asked about the delivery.
    (April 2004, Melbourne)

    Primigravida comes to your clinic for shared care. Her obstetrician is 30 km away. At 26/40, the FH was 28 cm, 4 weeks later FH is 40 cm. She feels tired and discomfort.
    Task: Relevant history
    Ask the examiner for findings and investigations
    Discuss the diagnosis and management with the patient
    (U/S shows no abnormality of baby, no fever, no PIH, GCT normal, discuss the risk of preterm labour, refer the baby to OB…etc)
    (April 2004, Melbourne)

    History:
    Did you remember your last period exactly? (check date)
    Do you have any fever, flu or painful passing urine lately? (infection)
    Have you had any U/S scan before?
    Have you had screening test for fetal anomaly before?
    What is your blood group?
    Do you have DM or have you had your blood sugar checked?
    Is there anyone in your family has diabetes?
    How is your baby movement?
    If had baby before, what was his/her birth weight?

    Physical examination:
    GA: if obesed, FH is not reliable, ask for BMI
    V/S
    FH: feel any water? Fluid thrill

    Investigation:
    GCT
    U/S
    Urine exam: sugar?
    Rh
    CTG (by obstetrician)

    If DM à monitor blood sugar
    Increase exercise and diet control for about 1 week if PP sugar > 6, introduce insulin and U/S every 4 weeks

    Cause of size>date:
    · Large constitution
    · Polyhydramnios
    · Wrong date
    · Multiple pregnancy
    · Macrosomia from DM
    · Hydrops from Rh- mother

    If polyhydramnios in this case
    Risk:
    · Preterm labour
    · PROM
    · Cord prolapse on delivery
    · Unstable lie: malpresentation
    · Aruptio placenta
    · PPH

    Might use NSIDS but consider the risk of premature closure of PDA
    Amniocentesis is the last source, if mother is very distress but increase risk of infection and most cases end up with preterm labour

    Inform her obstetrician and refer to tertiary centre immediately for CTG and management.

    O&G p.146
    Minor degree: May sedate at night
    Worse by 30-35 wk: Amniocentesis < 500 ml each time but lead to infection and preterm labour.
    >35 weeks: Amniocentesis and labour
    Release fluid slowly to prevent cord prolapse. PPH is likely and prophylaxis oxytocin should be given.
  15. OTD

    OTD Guest

    A 28 years old lady delivered a healthy baby by C/S 2 years ago. Now she wants to be pregnant again but she doesn’t want to deliver the baby by C/S. She wants a normal vaginal delivery.
    Task: History
    Tell her whether she can deliver by C/S or V/D
    Explain her details

    (August 2004, Melbourne)

    Questions to ask:
    How long was your labour?
    Why did you have C/S?
    o If breech, fetal distress, poor progression, not due to CPD à it is possible to have VBAC: success rate is 70%
    o If due to CPD: success rate is 50-60%
    How much dilated before went for C/S?
    o If 6 cm à can go VBAC
    How weight the baby was at birth?
    Did you have any medical problems such as DM during the last pregnancy?
    Is there any DM in your family?
    What don’t you want a C/S?

    VBAC: Risk of rupture uterine
    · 0.4-0.5% in low segment
    · 2-5% in classic incision

    VBAC can be done 1-2 years after scar healed and induction is not possible.

    Depend on indication for C/S in previous pregnancy if it was obstructed labour, it’s better to repeat C/S
  16. OTD

    OTD Guest

    A woman in her 37th week of pregnancy comes to discuss the result of a vaginal swab, which is GBS positive.
    Task: Explain, advice and management
    (September 2004, Adelaide)

    28/40 week, with GBS positive and vaginal candidiasis with no signs and symptoms.
    (Chandrika)

    20-30% of normal population have GBS positive without signs and symptoms
    6-30% of pregnant women have GBS positive in upper vaginal

    There is small percentage of transmission from mother to baby (1-2%) but if infected, it’s very severe: can die from septicemia and need multiple ABO so it’s better to have treatment.

    Mother should have loading dose and another dose of ABO to cover, if not, baby must have full screening.

    Penicillin 1.2 gm loading dose then 600 mg IV 4 hourly during the labour or
    Erythromycin 500 mg oral qid
    No need to treat asymptomatic vaginal candidiasis.

    If baby is infected, give Penicillin 100 mg/kg until every test is negative.

    Routine screening: Low vaginal swab at 26-27 wk
    It is debatable about IV ABO, fromO&G p.140 suggested that it’s effective in premature labour, PROM >12 hr, previously had infected baby à decrease neonatal morbidity.
  17. OTD

    OTD Guest

    25 year-old lady primigravida 30/40 week in rural hospital presents with leaking PV.
    Task: Further history
    Ask the examiner for findings
    Explain the management to the patient
    This was PROM case, confirmed by Fern test. I transferred to tertiary hospital and did the usual counseling as onset labour, fetal monitoring, preterm baby and social support

    (May 2004, Adelaide)

    In 2nd trimester consider risk of
    Preterm: Lung and LN development
    Chorionitis
    Fetal distress
    If delivery: Good outcome 5%
    Bad outcome 95%

    If 28-36 week: Viable
    Conservative until 34-35 week
    Don’t stay at home: Admit for choriioamnionitis monitoring
    o Speculum, U.S
    o Vaginal swab
    o No PV
    Give Erythromycin in PROM until get the result of vaginal swab
    CRP and ESR every 2-3 days
    FHRM, temperature

    If want to go home à come to hospital every day to check abdomen and temperature

    If going to delivery à need neonatal unit for premature chance so need to transfer to tertiary hospital. If < 34 week, give steroid 24 hour

    Mum has to know the expected outcome
    At 37 week:
    o Sucking reflex
    o Temperature control
    Survival at 28 week is 75%

    35-36+ week (near term)
    Give 24 hour then induction, normally PROM at this time
    75% delivery in 24 hours
    90% delivery in 1 week
  18. OTD

    OTD Guest

    Contraception for post-partum woman.

    Breast feeding
    3-4 times a day and at least 1/night
    Chance for pregnancy 2-5%
    After 6 months 15%
    Can give progesterone only as oestrogen suppresses milk production
    SE of progesterone only
    o Depression
    o If fail à high risk of ectopic pregnancy
    6 week post-partum, advice IUCD, implant, minipill (need fixed time and if miss à 7 days rule

    Depo Provera
    Progesterone, inject every 2 months (3 mo from RWH)
    After 1 year à no period

    Implant (Implanol)
    Last for 3 years
    Day procedure, cost~30-40$
    Need to be sure that the couple doesn’t want more children in 3 years.
    Can be done before discharge, in the same admission

    IUCD
    Wait for 6 weeks, until uterus is back to normal size
    Before that, increase risk of perforated uterus

    When will I ovulate?
    Ovulation returns in 3-9 months
    Most women have period in 6 months
    When stop breast feeding à can go back to normal OCP (oestrogen)
    If she doesn’t want to breast feed, she can start OCP straight away.
  19. OTD

    OTD Guest

    A 28 years woman had normal pregnancy 2 years ago with DVT and PE 3 days after labour. She plans for another pregnancy and comes to see you for counseling.
    (Adelaide, April 2005)

    Questions to ask:
    Any PH of DVT, apart from pregnancy?
    PH and FH of DVT and coagulation factor
    OCP
    BMI, smoking
    Previous pregnancy history: C/S?
    Any varicose vein?
    Has thrombophillia been screening?

    If PH of DVT with risk factor à no need to prophylaxis.
    If FH of DVT, coagulation defect à prophylaxis during PP period.
    If PH of DVT in the previous pregnancy à prophylaxis during pregnancy, not PP.

    Give Claxane (low-molecular weight heparin) until 36 week (can’t reverse) à then heparin à PP use claxane or warfarin (can breast feed)

    Refer to OB
    Drink more water and increase mobilization and exercise during pregnancy.
  20. OTD

    OTD Guest

    Primigravida, 18/40, U/S finds twin pregnancy, two placenta with thick wall of sacs in between the fetuses, normal placenta.
    Task: Tell the patient the result of the U/S
    Talk to her as regard the management, what she needs to know
    You can ask brief history and findings
    (Sydney, March 2004)

    She didn’t take any folic acid during early pregnancy, blood O+, can feel fetal movement. No history of severe N/V, no headache and blurred vision, urine exam in normal.

    This is diamniotic-dichorionic twin à low risk pregnancy. It’s less likely to have twin-transfusion syndrome.
    Tell her that she’s carrying two babies and they seem to be alright.

    If old age à discuss about Down’s syndrome screening.

    Risk:
    Hyperemesis gravida
    High diet desire à Fe, Folic acid, Ca
    ­ Risk of pregnancy
    ­ Preterm delivery
    ­ PPH
    ­ PROM
    ­ Hospitalization
    ­ PIH

    If she Rh-, give anti-D, unless she’s been immunized, at 28, 34 week and PP within 24 hour

    Need more support and social worker.
    More visits and more U/S

    Vaginal delivery is possible if:
    1st baby is head presentation à if not, C/S at 38 week
    Not monoamniotic-monochorionic twin à C/S at 32 week, survival is great.

    A 27 years old lady had a baby with spina bifida, comes for advice as she plans to get pregnant.
    · Counseling

    Increase chance 5% than normal population
    Folic acid 3 months before conceive
    * Normal 500mg
    * In her case 4-5 mg (10 times higher)

    NTD test: Diagnostic tests
    Maternal serum screening at 14-15 week, esp. AFP
    U/S at 18-19 week
    a. At 12 week can Dx anencephaly
    b. At 18-19 week can Dx NTD
    No invasive procedure, however, spina occulta cannot be diagnosed easily

    If she still has NTD baby à can offer termination
    Advice her about genetic counseling and folic acid
    General pre-conception counseling and blood test as usual
  21. OTD

    OTD Guest

    A 27 years old lady had a baby with spina bifida, comes for advice as she plans to get pregnant.
    · Counseling

    Increase chance 5% than normal population
    Folic acid 3 months before conceive
    * Normal 500mg
    * In her case 4-5 mg (10 times higher)

    NTD test: Diagnostic tests
    Maternal serum screening at 14-15 week, esp. AFP
    U/S at 18-19 week
    a. At 12 week can Dx anencephaly
    b. At 18-19 week can Dx NTD
    No invasive procedure, however, spina occulta cannot be diagnosed easily

    If she still has NTD baby à can offer termination
    Advice her about genetic counseling and folic acid
    General pre-conception counseling and blood test as usual
  22. OTD

    OTD Guest

    A 29 years old nulliparous wowan, has pain on menstruation and with sexual relationship with her husband.
    · Relevant history
    · Relevant finding
    · Management
    (Sydney, March 2004)

    Pain all through menstruation and on deep penetration. Menarch and menstruation are regular, no spotting and no discharge. No smoking, no alcohol, been healthy before.
    O/E: Retroversion uterus, no d/c, nodules felt posteriorly (Douglas pouch) and tender at posterior fornix.

    Questions to ask:
    Pain, is that cyclic pain?
    Peri-menstrual bleeding
    Cycle history and menstrual history
    Multiple partners? (Ddx with PID, in young lady)

    Findings:
    GA, abdomen
    Speculum (not specific)
    PV: might pain on deep bimanual palpation

    What is endometriosis?
    Normal uterus tissues goes somewhere else.

    Why does it cause pain?
    Due to bleeding inside and post-scaring
    20-30% related to retrovert uterus but normal also can cauase if have scar that cause retrovert

    U/S is not useful but might see cyst in ovary
    Diagnosis based on history and Laparoscopic diagnosis

    Can prescribe NSAIDs but “Gold standard” treatment is laparoscopic endometriectomy

    Will it affect my fertility?
    Yes, egg cannot be transferred or problem with implantation. If try to get pregnant for 12 months à need investigation for infertility

    This case, need to refer Gynecologist for more investigation.
  23. OTD

    OTD Guest

    18 years old girl with primary amenorrhea. All secondary sexual signs have been presented for 3 years. FH of puberty delay, mother had menarche at the age of 17.
    (Melbourne, April 2004)

    Questions to ask:
    Normal birth, growth and development?
    When did she have breast and pubic hair?
    o Breast à pubic hair à growth spurt à menarche
    Height and weight to r/o Turner’s syndrome; stress ovary
    FH: mother’s menarche (constitutional delay)
    Is she doing well at school?
    Does she do excessive exercise? Anorexic?

    Finding:
    GA (any stigmata of Turner’s syndrome), breast, pubic hair
    Abdominal mall? If lump with cyclic pain à might be imperforated hymen (bulging of rigid hymen +/- small opening)
    Is she sexually active?
    o If yes, full examination
    o If no, external genitalia is enough
    If blind ending vagina: Mullerian agenesis (noCx, noUt, have Vg)
    Turner’s syndrome:
    o Streak ovary
    o Short stature
    o Deformity
    o Confirm Dx by U/S and karyotype

    Ddx:
    · Constitutional delay
    · Turner’s syndrome
    · Mullerian agenesis
    · Anorexia
    · Imperforated hymen
    · Primary ovarian failre

    If everything is normal (including U/S +/- karyotype) à wait another 1 or 2 years.

    Can try estrogen-pregesterone à withdrawal bleeding for primary ovarian failure

    Investigation:
    FSH, LH to r/o ovarian failure
    U/S
    Karyotype

    If constitutional delay, can treat with hormone challenge if >16 years old.
    If delay growth à might give GH + oestrogen
    Refer but discuss the options for Ix and treatment
  24. OTD

    OTD Guest

    A 28 years old man with 12 month-infertility, his wife’s investigation for infertility is normal. His semen: volume 6 ml, motility is 95%, with severe oligospermia and morphology is 30%.
    · History taking
    · Finding you want
    · Management

    Questions to ask:
    Is this first time marriage? How is your wife, is this first time as we;;?
    Have you had any children before? How about your wife?
    Any infection or problem with water word? Painful passing urine?
    Any radiation, medication, surgery?
    How is your relationship? Sexual activity? Impotence?
    How is your job? Work place (warm decreases sperm). Any stress?
    Drug, smoking, alcohol

    Finding:
    GA, height and weight
    Abdomen: any mass?
    Testicular mass?

    Repeat sperm count (always)
    Advice about excessive temperature
    Options for IVF
    1 cycle success rate is about 25%
    3 cycles success rate is about 40%
    Cost around 1-2,000 $ per attempt
    Intracytoplasmic sperm injection has a bit better success rate for morphology abnormality.

    Refer to infertility clinic
    Investigation that can do
    Repeat sperm count
    U/S testis
    Testosterone
    Testicular biopsy by specialist
  25. OTD

    OTD Guest

    A 20 years old lady has pelvic pain and discharge. Vaginal swab for Chlamydia is positive. Her boyfriend is overseas.
    · Counseling and Management

    Questions to ask:
    Is this first time of symptoms?
    Contraception? IUCD
    Safe sex?
    How many partners?
    How is your boyfriend, does he have any symptoms?

    Even treated, Chlamydia can affect fertility, cause PID and chronic pain à Do U/S to exclude TOB if suspected

    Man: Unaware of s/s, might get it before

    Offer STD screening, safe sex and explore about sexual experience with others à should contact them to check

    Treatment:
    - Doxycyclin 100 mg bid for 14-21 days
    - Ertythromycin 1 gm IV stat with partner (if pregnant)
  26. OTD

    OTD Guest

    A pregnant lady GA 37/40, comes with breech presentation. She is primigravida and wants to know her options.

    Explain what breech presentation is. U/S to find the cause of breech.

    Cause of breech
    Abnormal baby: macrosomia, anencephaly
    Abnormal uterus or placenta and passage: Fibroid, placenta previa, retracted pelvic

    These are the options, tell benefits and risk
    Breech if mobile, can turn by itself

    External cephalic version (ECV)
    37-38 week, under U/S guide
    Complication is tear cord and placenta, acute fetal distress à might need urgent C/S (rare)

    Breech trial has very poor outcome, not worth to do and only can be done in multipara. This case C/S is indicated.

    U/S, offer ECV even it’s fixed, REFER to OB
    Tell her that vaginal trial has poor outcome but can try. She can decide what she wants.
  27. OTD

    OTD Guest

    Miss Howe is a 22 years old woman with two children and would like to be sterilized. Obtain informed consent for tubal sterilization.
    More history:2 children
    Partner, father of second child
    No work, partner is also unemployed
    She doesn’t like the pill

    Management
    Explore relationship: stable?
    Talk about other contraception:
    # Male sterilization: easier
    # IUD (Mirena): carry risk of infection esp. this case; more chance of having more than one partner and unstable relationship
    # Implantation: last about 3 years (Implanon)
    Explain pros and cons of sterilization
    # If fail, increase risk of ectopic pregnancy
    # reverse rate is very poor: 25-70% and still increase ectopic pregnancy after reverse
    # reverse procedure is not cover by medicare
    # long waiting list
    Explain about laparoscopy and surgery of tubal ligation
    Give another contraception before she leaves as she has to be on contraception while she is in the waiting list

    (Hello Mrs. Howe, I’m Dr……., I understand that you come to see me today because you want to do permanent sterilization. I would like to ask you a few questions and the condition related to you, is that alright?

    You are 22? Do you have children? How many? Are you sure that you don’t want to have any more children in the future?
    Do you have a partner? Does he know about your decision? Does he agree?
    Why do you want to be sterilized?

    Do you know about other contraception methods such as oral contraceptive pills, coils, condoms, diaphragm and cups? There is also an implantation for contraception that is very effective and can be used for about 3 years each time. Have you heard about that? Are you interested in considering that?

    What do you know about female sterilization?
    Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked (draw diaphragm). This stops eggs moving down to meet sperms.

    The operation can be done in several ways, the most common method is by laparoscopy or a key hold surgery. This is usually done under general anesthesia, where you will be put to sleep. A doctor will make 2 tiny cuts, one just below your nevel and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope, it is a thin telescope-like instrument with lense to look at your reproductive organs.

    Another common way is by mini-surgery, usually you will be put to sleep as well. A doctor will make a small cut in your tummy, just below the bikini line to reach the tubes.

    You need to stay in the hospital, usually a couple of days, depending on types of anesthesia and operation. After operation, if you have general anesthesia, you might feel unwell for few days and may have some bleeding and pain, which is slight.

    You must consider sterilization as permanent method of contraception. However, there is an operation to reverse it but it is complicated and may not work, Medicare doesn’t cover for that either.

    The failure rate of female sterilization is 0.1-0.3%. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy, which is very dangerous.

    The advantage is that it does not interfere with sex, your womb and ovaries will remain in place. Ovaries will still release an egg every month and your sex drive and enjoyment will not be affected. Actually, they may improve as fear of pregnancy is no more an issue. Occasionally, some women might find their period becomes heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as you feel comfortable.

    You must continue contraception until time of operation as now you are put in a waiting list. If you use IUCD, it should be left until the next period. You should contact your doctor if you think that you are pregnant or if you miss a period and especially if it is accompanied with tummy pain.)

    A 37 years old woman is considering pregnancy in next few months. She is anxious about her risk of Down syndrome and has come to you regarding prenatal counseling. Your task is to counsel her.

    Management
    History of other risks such as DM, HT
    FH of chromosomal abnormality: Down’s syndrome, cleft lips, cleft palate
    Tell about the risk of Down’s syndrome is each age group, compared to normal population
    Prenatal screening process for down syndrome
    Risk of fetal loss during the procedure
    If test is positive, refer to genetic counseling
    Ask if the tests are positive, what is she going to do? The investigation is not covered by medicare
    Other screening for preconception: Rubella, VZ, chicken pox
    Folic acid 3 months before and after conception

    Fact about Down’s syndrome screening
    Risk of Down’s syndrome:
    Normal population 1:600-700
    30 1:350-400 35 1:250 37 1:200
    40 1:100 43 1:50
    risk of 2nd child is 1:100
    Screening test
    1. Ultrasound for nuchal fold at 11-14 wk (12, first trimester)
    2. Maternal serum test for b-hCG (­), AFP and estriol (¯) at 15 wk (second trimester): These 2 tests can detect 85-90%, false positive 1%, if both are positive, then this is high risk pregnancy, have to
    3. Amniocentesis at > 16 wk, can detect 100%, fetal loss 0.5-1 % (1:200)

    (Hello Mrs……., I’m Dr……… How are you today? As far as I know, you want to get information about risk of Down’s syndrome, is that correct? Before we get to that point, I would like to ask you some questions, related to your planned pregnancy, is that O.K?

    You are 37 years old, is this your 1st pregnancy?
    Do you have any other medical problems such as high blood pressure, diabetes?
    Is there any genetic problems in your family such as Down’s syndrome, cleft lips or cleft palate?
    What do you about Down’s syndrome?

    Down’s syndrome is a genetic disorder that associated with advanced age mothers. In general population, the risk of having a Down’s syndrome baby is 1:600-700 and increased to 1 in 100 in 40 year-old mothers. In your case, at 37, the risk is about 1 in 200. You can get pregnant even though it is a high risk pregnancy as there are screening tests to detect Down’s syndrome during early pregnancy. Do you have any idea about that?

    Firstly, we can do ultrasound to detect any abnormality in fetus in the 1st trimester and then take blood sample from you to analyze in the 2nd trimester. There are several chemistries in you blood that can be tested, if they are higher or lower than normal, it can be suspected for Down’s syndrome and some abnormalities in baby. These two screening tests can detect about 85-90%, if both tests are negative, it is less likely to have a Down baby. On the other hand, if both tests show abnormal results, you will be then put in a high risk group and need to have another test done, which is a diagnostic test with 100% accuracy to detect Down’s syndrome. It is an invasive procedure, which called “Amniocentesisâ€, have you heard about that?

    Obstetrician will put a needle through your abdomen and womb to get cells of the baby from the fluid around him or her and then analyze. By this procedure, you can know the conclusive result whether the baby has Down’s syndrome or not.

    However, this procedure might damage the fetus but the percentage is quite low, about 0.5-1%, which is 1 in 200 of fetal loss. In you case, this chance is as same as the chance of having a Down’s syndrome baby.

    If your first 2 tests are normal, it is a very good news, if not, you still have a choice to have the confirmation test or not, it is all up to you. Even if the result show abnormal gene, it is also your choice to continue your pregnancy or terminate. You have to think about these things carefully, as the test is not covered by medicare.

    Have you seen children with Down’s syndrome?
    They share similar characteristics as well as inherit from their own parents. They are likely to have other medical problems such as heart disease, hormonal disorder and might have difficulty in feeding. However they can actually live in normal environment with some super-visions and they are quite loveable, fun and enjoy music.)

    A 20 years old woman who has stopped her OCP three months ago, comes with a history of irregular light period and abdominal discomfort for the last few weeks. She has come in with her partner to ED. Yours task is to access and discuss management.

    Pain comes and go at LLQ for 2-3 weeks, 2 days ago pain started to be more severe, got pain killer from GP but pain is getting worse. Slight Vg bleeding, not Vg discharge. She stopped pills as she wants to get pregnant.

    History: Hx of PID, LMP that was regular,
    Have you done a pregnancy test?
    Do you have any symptoms of pregnancy?

    PE: LLQ pain, speculum: brownish fluid, PV: os closed, tender at cervix
    Ix UPT, UA, U/S

    Ddx 1. Ectopic pregnancy
    Missed abortion (PE excluded)
    UTI
    Twist ovarian cyst
    PID
    Stop OCP
    Appendicitis (if right)

    Mx 1. Medical treatment by methotrexate and follow up
    Surgery
    Post explore lap., can’t drive for 6 weeks.

    (Hello, my name is ……., I’m a doctor for you today, what should I address you? As far as I know you have had vaginal bleeding with tummy pain. May I ask you some questions regarding to your problem? Do you want me to give you pain killer before we start?

    Can you describe the bleeding for me? Is it bright red? (MC) Or dark red or brown? (EP) Is there any clot?
    How many tampons or pads you use?
    Can you tell exactly where the pain is?
    What it feels like? Have you had the same pain before?
    Did the pain started before bleeding? (EP) or you saw bleeding then felt pain? (MC)
    What make pain better? Worse?
    Do you have other symptoms? N/V? Diarrhea? Anorexia? Vg discharge?
    How were your periods? Regular of irregular? When was you last period that was regular?
    Why do you stop pills?
    Have you done a pregnancy test? Do you think you are pregnant?
    Have you ever had ectopic pregnancy before? Any miscarriage?
    Any medical problems? Any medications?
    I would like to examine you, are you comfortable with that?

    Miss……., now, we have had a good look at you tests that we ran. And according to the results of the test, the examination and what you complained of, there is a high possibility that you have what we call “Ectopic pregnancy†that is a pregnancy outside your womb, this can be in the tubes between your womb and ovaries as in most cases or inside the tummy, which is very rare. As the pregnancy is not in the usual place, it cannot continue to term. I understand that it is very disappointing for you but this condition can be more serious as it may bleed suddenly and can be life-threatening. To avoid this, we have to admit you in the hospital and refer you to obstetrician, she or he will make a definite diagnosis by laparoscopy or key hold surgery. This is the procure by which we insert a tube with lense within a small incision in your tummy, after we put you to sleep, so we could look at your womb and tubes.

    The treatment of this condition, it can be done either by laparocopy to inject a medication (Methotrexate if sac is <3cm) or remove the pregnancy.

    Another way is by operation to remove pregnancy. Both ways of treatment, the doctor will try to preserve the tube, but if it is damaged by this condition, then the only way to deal with it is to remove the tube.

    Is everything clear? Do you want me to repeat anything for you?
    Are there any questions that you would like to ask me?
    You will remain for few days in the hospital (2-3 days).
    A 19 year-old woman, 28/40 week pregnant, primigravida, found BP 170/110 mmHg and urine protein 2+ at ANC clinic. She also has frontal headache
    Task: Relevant history
    Important findings and investigation
    Management

    Diagnostic criteria
    Mild 140/90
    Severe 160/110 (6 hours apart, 2 episodes)
    Associated symptoms
    Headache
    Visual disturbance
    Nausea/vomiting
    Epigastric discomfort
    RUQ pain à liver
    Swelling
    Signs
    Hyperreflexia
    Very excitable clonus
    Edema
    Investigations
    FBE: platelet
    LFT: increase AST, ALT
    Urine protein 24 hours
    Uric acid
    Coagulation
    Urea, creatinine
    HELLP Syndrome: Hemolysis
    Elevate Liver enzyme
    Low Platelet
    Management
    · Admit to assessment unit for 2 hours
    · Bed rest and repeat BP
    · Do blood test
    · Repeat urine or start urine 24 hours
    · CTG for fetus, U/S
    If BP is still high, manage HT à Call physician to treat HT and find associated disease
    If BP is settle down around 140/90 mmHg, normal LFT, urine, platelet, and baby is o.k., still admit until collect 24 hr-urine protein
    Try not to give hydralazine in a hurry
    D/C and follow up 2-3 times/week (home visit)
    If continue HT à hydralazine à MgSO4 when impending eclampsia and then plan to delivery.
    Continue MgSO4 until 24 hours post-partum. If everything tends to be normal and urine output is good à stop
    If not, continue MgSO4 until everything tends to be normal.

    A young lady, experienced traumatic F/D, 2 weeks post-partum, she feels restless and down.
    Task: Management

    Ddx: Postpartum depression

    History:
    What happened during the delivery? Maybe she had bad impression about her labour, they didn’t do C/S…..Baby got bruise and mark on face.
    How is your sleeping?
    How is your appetite?
    How is your energy level?
    Do you breast feed?
    Do you feel like harming yourself or others, especially baby?

    I really sympathize with youà make her feel comfortable to talk
    Social support for taking care of baby à rest and enough time to sleep
    Find out if anyone support for finance.

    Offer psychiatric refer but need to get consent from the patient for that, if she still has insight.
    Do you like to see a specialist or you have anyone you would like me to refer you to?

    If baby is in danger, can admit the baby to health scheme and contact human service.

    A 28 years old lady at GA 40 weeks. ANC is normal but she wants to know about labour is overdue.
    Task: Discuss management
    Counseling about prolonged pregnancy and post-term

    Findings:
    Recheck date
    CTG
    PV
    This case, CTG is done today and the result is fine, date is 40 weeks. PV shows bishop 2-3, fetal movement is 10 in 12 hours.

    Explain that it’s O.K. that the baby is overdue.
    · Only 4% deliver on due date
    · 60-80% deliver 1 week ±
    · 2-3% goes beyond 2 week (10-14 days after due date)
    However, if the pregnancy goes beyond 42 weeks, there is increase incidence of intrauterine death so we have to do CTG weekly.

    If she is extremely anxious and ¯ fetal movement:
    · CTG twice a week
    · U/S check amnio-fluid index (AFI)

    Tell the date to induce and explain about how to induce:
    · Start from Prostaglandin
    · ARM (When your cervix starts to open, we’ll break the water)
    · Oxytocin 10 unit + NSS 1000 cc start 40 drop/ hour, adjust with contraction every 5 min, until get 3-4 contraction/10 min. (We’ll give you hormone to make you start contraction, you can request epidural block if it’s too painful.)
    · If fail induction à C/S or F/E

    Complication of posterm
    · Meconium aspiration
    · Intervention labour

    Primigravida, comes to you requesting C/S. Discuss pros and cons.

    Pros: ¯ incidence of urinary incontinence
    Cons:
    · Risk of anesthesia
    · 6 weeks to heal
    · ­ Risk of DVT due to immobilization
    · Risk of fail lactation
    · ­ Risk of next C/S
    · ­ Incidence of placenta previa, aruptio placenta
    · ­ Postpartum risk
    · Not good to have many children: after 4-5 children, most cases end up with hysterectomy
    · ­ Rupture in uterine segment

    A pregnant lady 34/40, wants to have C/S due to husband is going overseas. Advice.

    No C/S when absent medical condition, advice seek 2nd opinion, might be OB or Paediatrician.

    I’m not happy to do it but you can seek second opinion for that

    A 58 year-old woman presents with acute PV bleeding
    Task: Ddx
    Management

    The important thing to ask is she’s undergone menopause or not.
    Ddx: Malignancy (Cervix or uterus)
    Atrophic vaginitis
    Polyps
    Drugs: Warfarin
    Coagulation defect
    HRT
    Trauma: postcoital bleeding

    History:
    Pap smear: 10 years ago (stop pap smear when 65, having 2 normal pap smear in the last 5 years)
    Menopause?
    Hysterectomy?
    Medication
    Trauma, sexual intercourse

    Physical examination:
    GA
    Lymph nodes
    Abdomen: mass?
    External genitalia
    Speculum examination:
    o Get biopsy if abnormal
    o Pap smear if normal
    PV
    PR if think about cancer

    Investigation:
    Transvaginal ultrasound: ³ 4 mm
    o Small endometrial biopsy (Pipple?)
    o No need for D&C
    o Hysteroscopy and D&C if many….(?)
    § If can’t tolerate, use GA
    Important investigations:
    o Pap smear
    o U/S transvagina
    o Endometrial sample (if ³ 4 mm) à if result is negative, 95% exclude cancer

    If grade 1, refer her to Gyne-oncologist for further management, might be hysterectomy and/or radiation.

    Vaginal Herpes Simplex type 2 in a pregnant woman.
    Task: Manage the case
    Addressing concerns
    (May 2005, Melbourne)

    If active lesion à C/S and when PROM < 6 hours
    If primary lesion à increase risk of fetal transmission.
    If repeated, less severe.
    Can give acyclovir, safe for fetus.

    Hepatitis B: Passive immunization at birth
    Get protected during pregnancy
    · Hepatitis immunoglobulin with Hepatitis B vaccine at birth and then at 1 and 6 months
    · Can have N/D or C/S

    Hepatitis C: If PCR is +ve, chance of vertical transmission is 5%
    If nipple is crack à no breast feeding
    If nipple is O.K. à O.K.

    HIV: 50% if N/D and mother is not treated
    25-30% if mother is not treated
    5% if mother is treated:
    · Zidovudine from 20th week then infant is also should be given.
    0.5% if mother is treated and C/S

    Genital Herpes (O&G p.141)
    Risk of transplacental transmission is 1:1000, more likely to happen in primary than recurrent infection.
    Risk is greater during childbirth, particularly if mother has developed a recurrence of the condition or is shedding the virus from her cervix.
    o A woman with a history of genital herpes need have no anxiety that her baby will be infected and may expect to be delivered vaginally, unless a recurrence of the infection or a new infection occurs during the pregnancy.
    o If a first infection or a recurrence of genital herpes occurs during the pregnancy, but has healed by the time labour starts, the woman may give birth vaginally.
    o If herpetic lesions are present when the membrane rupture or labour starts, a C/S should be performed to avoid the risk that the baby will acquire a herpetic infection during the passage through the birth canal.
    Take endocervical swab for viral culture every 2 weeks from the 34th week should be abandoned, as positive HSV-infective swabs do not predict the risk of the infant being exposed to herpes infection during birth.
    There may be a connection between genital herpes and cancer of the cervix, but that cancer is treatable if Dx early- ‘a smear a year’ is the rule.

    Mastitis – tender breast 4 days after delivery
    Task: History, diagnosis and management
    (May 2005, Melbourne)

    A 30 years old female, mother of a 4 weeks old baby boy, comes to see you complaining of feeling tired, fatigue and fever with some left side breast tenderness
    Task: Take relevant history
    Ask about the examination finding from the examiner
    Discuss the diagnosis with the patient
    (Midia’s tutorial)

    PE: Temp. 38.4
    Breasts: left is erythematous, tender, nipple-OK
    Ddx: Mastitis
    Breast abscess: treatment is I&D and admit

    · Start feeding from affected side first (soft tissue injury so baby can suck from affected side) so baby sucks more
    · Don’t stop breast feeding now because it’s important to empty the breast
    · Keep breast fed for 2-3 week then if the patient wants to stop, she can
    · Treatment by ABO (Flucloxacillin) for 10 days, paracetamol, cold cabbage leaf, no need to admit

    A lady who is 20 weeks pregnant, noticed yesterday that her 6 years old son has developed chickenpox rash. She is enquiring regarding her exposure to chickenpox.
    Task: Take relevant history and answer patient’s questions.
    (May 2004, Brisbane)

    If > 20 weeks, less chance to get infected.
    It is dangerous in pregnancy, complication could be even encephalitis is the baby.
    If contact early in the 1st trimester, can cause fetal anomaly.

    This case, check her serology for IgG and IgM
    If IgG is positive: no worry
    If IgG and IgM is negative: repeat in 2 weeks
    Consider give 12.5 units/kg of VZV immunoglobulin IM within 72 hour (or 7 days?) after exposure.

    O&G p.142
    · Primary infection can result in serious complication for both mother and baby as maternal immune system is less efficient.
    · Complications:
    § Pneumonia 10% in mother can lead to death
    § First trimester: fetal anomaly such as microcephaly, lung hyperplasia, cataract, IUGR, psychomotor retardation
    · If maternal infection becomes apparent 7 days before or after delivery, the baby is at risk of developing disseminated varicella infection as maternal Ab production will not yet be adequate.
    · If doubt about the Dx or previous history of infection à take blood for IgG and IgM
    · High risk: give VZV immunoglobulin IM
    · Severe maternal infection: Acyclovir 5-10 mg/kg every 8 hours.
    · Infected infant maybe given both VZIG and acyclovir

    OHCS p.216
    · If mother is affected 1 week before or 4 weeks after, the baby might get severe infection à isolate from other babies and give VZIG and acyclovir
    ·

    26/40 week pregnant is present for her regular check-up. Two weeks ago FH was 26 and now is 40 cm. No complaints, she is Rh+, GTT normal, U/S at 18 weeks was normal. The U/S is done today. There is a large amount of amniotic fluid and something wrong with the baby (?). I admitted because she lived 30 km from the hospital. The patient asked about the delivery.
    (April 2004, Melbourne)

    Primigravida comes to your clinic for shared care. Her obstetrician is 30 km away. At 26/40, the FH was 28 cm, 4 weeks later FH is 40 cm. She feels tired and discomfort.
    Task: Relevant history
    Ask the examiner for findings and investigations
    Discuss the diagnosis and management with the patient
    (U/S shows no abnormality of baby, no fever, no PIH, GCT normal, discuss the risk of preterm labour, refer the baby to OB…etc)
    (April 2004, Melbourne)

    History:
    Did you remember your last period exactly? (check date)
    Do you have any fever, flu or painful passing urine lately? (infection)
    Have you had any U/S scan before?
    Have you had screening test for fetal anomaly before?
    What is your blood group?
    Do you have DM or have you had your blood sugar checked?
    Is there anyone in your family has diabetes?
    How is your baby movement?
    If had baby before, what was his/her birth weight?

    Physical examination:
    GA: if obesed, FH is not reliable, ask for BMI
    V/S
    FH: feel any water? Fluid thrill

    Investigation:
    GCT
    U/S
    Urine exam: sugar?
    Rh
    CTG (by obstetrician)

    If DM à monitor blood sugar
    Increase exercise and diet control for about 1 week if PP sugar > 6, introduce insulin and U/S every 4 weeks

    Cause of size>date:
    · Large constitution
    · Polyhydramnios
    · Wrong date
    · Multiple pregnancy
    · Macrosomia from DM
    · Hydrops from Rh- mother

    If polyhydramnios in this case
    Risk:
    · Preterm labour
    · PROM
    · Cord prolapse on delivery
    · Unstable lie: malpresentation
    · Aruptio placenta
    · PPH

    Might use NSIDS but consider the risk of premature closure of PDA
    Amniocentesis is the last source, if mother is very distress but increase risk of infection and most cases end up with preterm labour

    Inform her obstetrician and refer to tertiary centre immediately for CTG and management.

    O&G p.146
    Minor degree: May sedate at night
    Worse by 30-35 wk: Amniocentesis < 500 ml each time but lead to infection and preterm labour.
    >35 weeks: Amniocentesis and labour
    Release fluid slowly to prevent cord prolapse. PPH is likely and prophylaxis oxytocin should be given.

    A 28 years old lady delivered a healthy baby by C/S 2 years ago. Now she wants to be pregnant again but she doesn’t want to deliver the baby by C/S. She wants a normal vaginal delivery.
    Task: History
    Tell her whether she can deliver by C/S or V/D
    Explain her details

    (August 2004, Melbourne)

    Questions to ask:
    How long was your labour?
    Why did you have C/S?
    o If breech, fetal distress, poor progression, not due to CPD à it is possible to have VBAC: success rate is 70%
    o If due to CPD: success rate is 50-60%
    How much dilated before went for C/S?
    o If 6 cm à can go VBAC
    How weight the baby was at birth?
    Did you have any medical problems such as DM during the last pregnancy?
    Is there any DM in your family?
    What don’t you want a C/S?

    VBAC: Risk of rupture uterine
    · 0.4-0.5% in low segment
    · 2-5% in classic incision

    VBAC can be done 1-2 years after scar healed and induction is not possible.

    Depend on indication for C/S in previous pregnancy if it was obstructed labour, it’s better to repeat C/S

    26 years old lady came to see you because she wants to be pregnant. She has a past history of termination of pregnancy at 14 weeks and wants to know about prognosis. (She is Rh-)
    (2003, Melbourne)

    28 years old lady, induced abortion 2 years ago. She wants to know about possible complication on future pregnancy
    Task: Relevant history
    Management

    Questions to ask:
    What were the reasons of having abortion?
    Was it induced abortion or spontaneous abortion?
    What procedure did you go through?
    How many weeks of pregnancy at that time?
    What is your blood group?
    Were there any complications such as infection, bleeding after that abortion?
    Where did you have an abortion?

    O&G p.112
    · There is no reduction of spontaneous abortion, preterm labour or fetal loss in a subsequent pregnancy.
    · An induced abortion preformed before 12 weeks in a well-equipped and staffed clinic is followed by complications.

    A woman in her 37th week of pregnancy comes to discuss the result of a vaginal swab, which is GBS positive.
    Task: Explain, advice and management
    (September 2004, Adelaide)

    28/40 week, with GBS positive and vaginal candidiasis with no signs and symptoms.
    (Chandrika)

    20-30% of normal population have GBS positive without signs and symptoms
    6-30% of pregnant women have GBS positive in upper vaginal

    There is small percentage of transmission from mother to baby (1-2%) but if infected, it’s very severe: can die from septicemia and need multiple ABO so it’s better to have treatment.

    Mother should have loading dose and another dose of ABO to cover, if not, baby must have full screening.

    Penicillin 1.2 gm loading dose then 600 mg IV 4 hourly during the labour or
    Erythromycin 500 mg oral qid
    No need to treat asymptomatic vaginal candidiasis.

    If baby is infected, give Penicillin 100 mg/kg until every test is negative.

    Routine screening: Low vaginal swab at 26-27 wk
    It is debatable about IV ABO, fromO&G p.140 suggested that it’s effective in premature labour, PROM >12 hr, previously had infected baby à decrease neonatal morbidity.

    A 25 year-old lady primigravida 30/40 week in rural hospital presents with leaking PV.
    Task: Further history
    Ask the examiner for findings
    Explain the management to the patient
    This was PROM case, confirmed by Fern test. I transferred to tertiary hospital and did the usual counseling as onset labour, fetal monitoring, preterm baby and social support

    (May 2004, Adelaide)

    In 2nd trimester consider risk of
    Preterm: Lung and LN development
    Chorionitis
    Fetal distress
    If delivery: Good outcome 5%
    Bad outcome 95%

    If 28-36 week: Viable
    Conservative until 34-35 week
    Don’t stay at home: Admit for choriioamnionitis monitoring
    o Speculum, U.S
    o Vaginal swab
    o No PV
    Give Erythromycin in PROM until get the result of vaginal swab
    CRP and ESR every 2-3 days
    FHRM, temperature

    If want to go home à come to hospital every day to check abdomen and temperature

    If going to delivery à need neonatal unit for premature chance so need to transfer to tertiary hospital. If < 34 week, give steroid 24 hour

    Mum has to know the expected outcome
    At 37 week:
    o Sucking reflex
    o Temperature control
    Survival at 28 week is 75%

    35-36+ week (near term)
    Give 24 hour then induction, normally PROM at this time
    75% delivery in 24 hours
    90% delivery in 1 week

    Contraception for post-partum woman.

    Breast feeding
    3-4 times a day and at least 1/night
    Chance for pregnancy 2-5%
    After 6 months 15%
    Can give progesterone only as oestrogen suppresses milk production
    SE of progesterone only
    o Depression
    o If fail à high risk of ectopic pregnancy
    6 week post-partum, advice IUCD, implant, minipill (need fixed time and if miss à 7 days rule

    Depo Provera
    Progesterone, inject every 2 months (3 mo from RWH)
    After 1 year à no period

    Implant (Implanol)
    Last for 3 years
    Day procedure, cost~30-40$
    Need to be sure that the couple doesn’t want more children in 3 years.
    Can be done before discharge, in the same admission

    IUCD
    Wait for 6 weeks, until uterus is back to normal size
    Before that, increase risk of perforated uterus

    When will I ovulate?
    Ovulation returns in 3-9 months
    Most women have period in 6 months
    When stop breast feeding à can go back to normal OCP (oestrogen)
    If she doesn’t want to breast feed, she can start OCP straight away.

    A 28 years woman had normal pregnancy 2 years ago with DVT and PE 3 days after labour. She plans for another pregnancy and comes to see you for counseling.
    (Adelaide, April 2005)

    Questions to ask:
    Any PH of DVT, apart from pregnancy?
    PH and FH of DVT and coagulation factor
    OCP
    BMI, smoking
    Previous pregnancy history: C/S?
    Any varicose vein?
    Has thrombophillia been screening?

    If PH of DVT with risk factor à no need to prophylaxis.
    If FH of DVT, coagulation defect à prophylaxis during PP period.
    If PH of DVT in the previous pregnancy à prophylaxis during pregnancy, not PP.

    Give Claxane (low-molecular weight heparin) until 36 week (can’t reverse) à then heparin à PP use claxane or warfarin (can breast feed)

    Refer to OB
    Drink more water and increase mobilization and exercise during pregnancy.

    Primigravida, 18/40, U/S finds twin pregnancy, two placenta with thick wall of sacs in between the fetuses, normal placenta.
    Task: Tell the patient the result of the U/S
    Talk to her as regard the management, what she needs to know
    You can ask brief history and findings
    (Sydney, March 2004)

    She didn’t take any folic acid during early pregnancy, blood O+, can feel fetal movement. No history of severe N/V, no headache and blurred vision, urine exam in normal.

    This is diamniotic-dichorionic twin à low risk pregnancy. It’s less likely to have twin-transfusion syndrome.
    Tell her that she’s carrying two babies and they seem to be alright.

    If old age à discuss about Down’s syndrome screening.

    Risk:
    Hyperemesis gravida
    High diet desire à Fe, Folic acid, Ca
    ­ Risk of pregnancy
    ­ Preterm delivery
    ­ PPH
    ­ PROM
    ­ Hospitalization
    ­ PIH

    If she Rh-, give anti-D, unless she’s been immunized, at 28, 34 week and PP within 24 hour

    Need more support and social worker.
    More visits and more U/S

    Vaginal delivery is possible if:
    1st baby is head presentation à if not, C/S at 38 week
    Not monoamniotic-monochorionic twin à C/S at 32 week, survival is great.

    A 27 years old lady had a baby with spina bifida, comes for advice as she plans to get pregnant.
    · Counseling

    Increase chance 5% than normal population
    Folic acid 3 months before conceive
    * Normal 500mg
    * In her case 4-5 mg (10 times higher)

    NTD test: Diagnostic tests
    Maternal serum screening at 14-15 week, esp. AFP
    U/S at 18-19 week
    a. At 12 week can Dx anencephaly
    b. At 18-19 week can Dx NTD
    No invasive procedure, however, spina occulta cannot be diagnosed easily

    If she still has NTD baby à can offer termination
    Advice her about genetic counseling and folic acid
    General pre-conception counseling and blood test as usual

    A 29 years old nulliparous wowan, has pain on menstruation and with sexual relationship with her husband.
    · Relevant history
    · Relevant finding
    · Management
    (Sydney, March 2004)

    Pain all through menstruation and on deep penetration. Menarch and menstruation are regular, no spotting and no discharge. No smoking, no alcohol, been healthy before.
    O/E: Retroversion uterus, no d/c, nodules felt posteriorly (Douglas pouch) and tender at posterior fornix.

    Questions to ask:
    Pain, is that cyclic pain?
    Peri-menstrual bleeding
    Cycle history and menstrual history
    Multiple partners? (Ddx with PID, in young lady)

    Findings:
    GA, abdomen
    Speculum (not specific)
    PV: might pain on deep bimanual palpation

    What is endometriosis?
    Normal uterus tissues goes somewhere else.

    Why does it cause pain?
    Due to bleeding inside and post-scaring
    20-30% related to retrovert uterus but normal also can cauase if have scar that cause retrovert

    U/S is not useful but might see cyst in ovary
    Diagnosis based on history and Laparoscopic diagnosis

    Can prescribe NSAIDs but “Gold standard†treatment is laparoscopic endometriectomy

    Will it affect my fertility?
    Yes, egg cannot be transferred or problem with implantation. If try to get pregnant for 12 months à need investigation for infertility

    This case, need to refer Gynecologist for more investigation.

    18 years old girl with primary amenorrhea. All secondary sexual signs have been presented for 3 years. FH of puberty delay, mother had menarche at the age of 17.
    (Melbourne, April 2004)

    Questions to ask:
    Normal birth, growth and development?
    When did she have breast and pubic hair?
    o Breast à pubic hair à growth spurt à menarche
    Height and weight to r/o Turner’s syndrome; stress ovary
    FH: mother’s menarche (constitutional delay)
    Is she doing well at school?
    Does she do excessive exercise? Anorexic?

    Finding:
    GA (any stigmata of Turner’s syndrome), breast, pubic hair
    Abdominal mall? If lump with cyclic pain à might be imperforated hymen (bulging of rigid hymen +/- small opening)
    Is she sexually active?
    o If yes, full examination
    o If no, external genitalia is enough
    If blind ending vagina: Mullerian agenesis (noCx, noUt, have Vg)
    Turner’s syndrome:
    o Streak ovary
    o Short stature
    o Deformity
    o Confirm Dx by U/S and karyotype

    Ddx:
    · Constitutional delay
    · Turner’s syndrome
    · Mullerian agenesis
    · Anorexia
    · Imperforated hymen
    · Primary ovarian failre

    If everything is normal (including U/S +/- karyotype) à wait another 1 or 2 years.

    Can try estrogen-pregesterone à withdrawal bleeding for primary ovarian failure

    Investigation:
    FSH, LH to r/o ovarian failure
    U/S
    Karyotype

    If constitutional delay, can treat with hormone challenge if >16 years old.
    If delay growth à might give GH + oestrogen
    Refer but discuss the options for Ix and treatment

    A 28 years old man with 12 month-infertility, his wife’s investigation for infertility is normal. His semen: volume 6 ml, motility is 95%, with severe oligospermia and morphology is 30%.
    · History taking
    · Finding you want
    · Management

    Questions to ask:
    Is this first time marriage? How is your wife, is this first time as we;;?
    Have you had any children before? How about your wife?
    Any infection or problem with water word? Painful passing urine?
    Any radiation, medication, surgery?
    How is your relationship? Sexual activity? Impotence?
    How is your job? Work place (warm decreases sperm). Any stress?
    Drug, smoking, alcohol

    Finding:
    GA, height and weight
    Abdomen: any mass?
    Testicular mass?

    Repeat sperm count (always)
    Advice about excessive temperature
    Options for IVF
    1 cycle success rate is about 25%
    3 cycles success rate is about 40%
    Cost around 1-2,000 $ per attempt
    Intracytoplasmic sperm injection has a bit better success rate for morphology abnormality.

    Refer to infertility clinic
    Investigation that can do
    Repeat sperm count
    U/S testis
    Testosterone
    Testicular biopsy by specialist

    A 20 years old lady has pelvic pain and discharge. Vaginal swab for Chlamydia is positive. Her boyfriend is overseas.
    · Counseling and Management

    Questions to ask:
    Is this first time of symptoms?
    Contraception? IUCD
    Safe sex?
    How many partners?
    How is your boyfriend, does he have any symptoms?

    Even treated, Chlamydia can affect fertility, cause PID and chronic pain à Do U/S to exclude TOB if suspected

    Man: Unaware of s/s, might get it before

    Offer STD screening, safe sex and explore about sexual experience with others à should contact them to check

    Treatment:
    - Doxycyclin 100 mg bid for 14-21 days
    - Ertythromycin 1 gm IV stat with partner (if pregnant)

    A pregnant lady GA 37/40, comes with breech presentation. She is primigravida and wants to know her options.

    Explain what breech presentation is. U/S to find the cause of breech.

    Cause of breech
    Abnormal baby: macrosomia, anencephaly
    Abnormal uterus or placenta and passage: Fibroid, placenta previa, retracted pelvic

    These are the options, tell benefits and risk
    Breech if mobile, can turn by itself

    External cephalic version (ECV)
    37-38 week, under U/S guide
    Complication is tear cord and placenta, acute fetal distress à might need urgent C/S (rare)

    Breech trial has very poor outcome, not worth to do and only can be done in multipara. This case C/S is indicated.

    U/S, offer ECV even it’s fixed, REFER to OB
    Tell her that vaginal trial has poor outcome but can try. She can decide what she wants.
  28. OTD

    OTD Guest

    AMC CLINICALS OBS /GYNAE

    --------------------------------------------------------------------------------

    Gestational DM

    Gestational DM starts from 20 or 25 Wk (which one?)

    History taking:
    FH of DM
    Previous pregnancy: N/D or C/S, any complication such as bleeding?
    Previous baby: How big was the baby?
    S/S of DM: polyuria, polydipsia, blurred vision
    BP (DM associated with PIH)
    Was the blood sugar checked?
    Was it the plan pregnancy?

    Physical examination:
    GA
    Abdomen: lie and size of the baby
    Might do fundoscopic examination à refer to ophthalmologist

    Investigation:
    If GCT was done before à do GTT
    If GTT was done before à repeat GTT
    U/S to see how big, position
    FHR and CTG

    Management:
    Refer to the hospital for assessment and monitor* (might need admission)
    Team management*
    Tell her that she has gestational diabetes and explain about DM, after delivery BS will return to normal, about 40-60% may develop DM in the future.
    Explain about complication
    a. Complication to mother and pregnancy
    · 40-60% develop DM in the future
    · 2nd baby might be big
    · Long labour
    · Polyhydramnios
    · Pre-eclampsia
    · Bleeding (PPH)
    · PROM
    · ­ risk of obstetric intervention
    · Bleeding from placenta
    b. Complication to the baby
    · Hypoglycaemia after birth
    · Shoulder dystocia
    · Prematurity
    · Cord prolapse
    · Big baby
    That’s why we need to monitor your diabetes to prevent and detect complication earlier.
    Life style change: diet control for few weeks then if the blood sugar can’t be controlled, go for insulin (no tablet).
    Why I can’t take tablet?
    It’s not enough time to absorb tablets and you might have N/V that decreases the efficiency of the medication.
    Regular follow up
    c. Sugar level 3-4 times/day
    d. Urine protein
    e. CTG every week after 32 week
    f. U/S every 4 weeks
    g. Check kidney function

    Tell her that she might to deliver before term, when the lung is mature enough.



    Rape

    A 27 years old lady, was raped by Johnny 2 days ago. Management.

    Rapport and introduction: Make her to open
    I understand that it’s very distressing for you and I’m very sorry for you.
    Are you comfortable to talk about this today?
    Do you want a glass of water?
    I’m very appreciated that you talk about this with me.
    It’s safe here and everything we talk about it’s confidential.

    History taking:
    Can you tell me more about that?
    Have you been seen by any doctor so far?
    Have you talked or shared this information with somebody?
    Do you know Johnny? Is this the first time you’re raped? Are you safe at home? (chance to be raped again)
    When was your last period? Is your period regular?
    Are you using any contraception?
    Was it sexual intercourse? Was it penetration?
    Do you feel guilty? Do you feel like harming yourself?
    How is your mood, eating, sleeping, energy level?
    Do you want to report the police?
    What is your major concern at this stage?

    Admission criteria:
    · Suicidal idea
    · Not eating
    · Bleeding
    · Not safe at home

    Examination:
    If she wants to report to police à refer her to see gynaecologist to get sample and rape department (?) for record. Don’t touch her!

    If she doesn’t want to à keep her clothes for 2-3 months, take swab for STD, STD screening: HIV, Hep B&C, Chlamydia, STD
    Anytime you change your mind to report, I’ll still have your clothes as evidence.

    Points**
    Never push her to report
    STD screening & take swab & HIV counseling
    Keep clothes for 3 months
    Post-coital contraception: most important** à 94% protection
    · Postinor 2 tablets now and 2 tablets in the next 12 hours
    · Come back if miss period
    CASA: organization for rape

    Home Delivery

    A 26 year-old lady, 12/40 week, comes to you for advice about home delivery.

    History:
    Why do you prefer home delivery?
    What do you know about it so far? Would you like me to tell you more about this?
    Is this your first pregnancy?
    If it’s 2nd pregnancy:
    · Any complications
    · Was it N/D or C/S?
    · How long was the labour?
    · Any bleeding after the labour? Problems during PP
    If it’s 1st pregnancy:
    · Advice that it’s better to have a hospital delivery because anything can go wrong during delivery.

    Common situations are:
    I hate hospital
    I had a bad experience with my first labour

    Counselling:
    During pregnancy à exclude chronic condition such as DM, HT.
    There are several complications that might happen during pregnancy and delivery such as
    Too big or too small baby
    PROM
    Malpresentation à can’t be delivered by N/D
    Medical conditions à DM, HT

    Home delivery is fine if the pregnancy is normal and delivery can be done by vaginal birth. However, there are few complications that might develop during pregnancy and labour.

    Home delivery
    You are going to be there with 1 midwife at home but tell the hospital about your expected date of delivery
    Advantages:
    Nobody there except midwife and your family members. You’ll be surrounded by the one you love.
    More comfort and less distress.
    ¯ need of pain killer à if need, epidural can’t be given
    Disadvantages:
    Only 1 midwife with you, if anything goes wrong, she might not pay 100% attention to both of you and your baby.
    30% of N/D at home ends up in hospital, that’s why we need to let the hospital know your expected date of delivery, in case you need to be admitted in the hospital.
    Complications with baby such as mucus aspiration and fetal distress, which need to be seen by paediatrician. These are serious complications that might cause a chance of baby dealth.
    Serious complication: cord prolapse, which need to be delivered by C/S as soon as detected.

    Talk about hospital delivery
    There is a birth unit that you can come and have a look. Your baby will also be delivered by the midwife and there are paediatrician and obstetrician around. If anything goes wrong they are just 1 room away. If everything is alright, midwife will do the delivery for you.

    You can start attending anenatal class and you can talk and know midwives. You can also choose the midwife whom you like for your delivery.

    Take times to think about that again before make decision. Here is pamphlet about home and hospital delivery.

    Polyhydramnios

    You’re a GP at countryside clinic, a lady comes for shared care. At 28/40 week, FH is 32 cm. Management.

    DDX:
    Wrong date (50-60%)
    Polyhydramnios
    Multiple pregnancy
    DM
    Fetal abnormality
    Constitutional big baby

    History taking:
    Is this a first pregnancy? If not, what is the 1st baby birth weight?
    What are your husband and your blood group?
    Any history of abortion? Any bleeding during pregnancy?
    Did you have an U/S done? When was it? Was it single baby? Any anomaly? (r/o 1, 3, 5)
    Was the pregnancy normal so far?
    Mother symptoms: Do you feel any discomfort? How is your sleep? Any N/V, tired:
    · If acute polyhydramnios
    § GA DM: oedema, tiredness, polydipsia, polyuria
    § Twin transfusion syndrome
    Hx of DM, FH of DM, previous big baby? FH of multiple pregnancy?

    Physical examination:
    GA: obesed?
    H&L
    Abdomen: palpation à lie presentation; Can I feel the baby? Any tenderness?
    Oedema
    Signs of diabetes
    May look at vagina but not relevant à mass, fibroid can confirm by U/S

    Investigations:
    U/S
    GCT or GTT
    Blood group and Rh
    CTG


    Management
    Life style modification
    a. Eat small amount, more often
    b. ¯ Exercise
    2. Talk about complication of the cause

    Polyhydramnios
    Reassurance
    Refer to obstetrician to exclude serious complication
    · If very discomfort (5%) à can take the fluid out
    Associated complication:
    · Malpresentation and might need OB intervention
    · Cord prolapse
    Still a chance of N/D

    GA DM
    All newly diagnosed GA DM à admit 24 hour for assessment (urine protein 24 hour)
    Team management

    Multiple pregnancies
    F/U more often
    Complications:
    · ­ Risk of PROM
    · ­ Risk of PPH
    · Twin transfusion syndrome
    · ­ Risk of preterm
    · ­ Chance of cerebral palsy of the 2nd baby in delivery (5times)
    · ­ Risk of OB intervention à C/S

    Fetal anomaly
    Refer to OB à baby may not survive

    Constitutional big baby
    Monitor baby but have to do U/S to correct date
    Normally delivery at 38 week
    Complications:
    · ­ Chance of shoulder dystocia
    · Obstructed labour à C/S
    · May delivery preterm




    Depo Provera

    A 27 year-old lady, comes to see you as a GP and wants to discuss about Depo Provera. Task is management.

    Why do you want to have Depo Provera?
    Have you had it before?
    Have you been told about complication and side effects of Depo Provera?
    After I explain about Depo Provera, I’d like to tell you more about other methods of contraception?

    What is Depo Provera?
    It’s a injectable form of contraception, containing progesterone.

    How does Depo Provera work?
    Through normal menstrual cycle, there are 2 hormones called oestrogen and progesterone. There is fluctuation of these 2 hormones, one is up, one is down throughout the cycle. By injecting Depo Prevera, which contains progesterone, the fluctuation is less, therefore the egg would be either not released or released but infertile. Even sperm reaches the egg, it’s not going to be fertile as the absence of thickening of the endometrium.

    Common SE:
    Breast tenderness
    N/V
    80% weight gain
    Complications:
    1/3 ­ bleeding: spotting, heavy
    1/3 no bleeding
    Irreversible for infertility for 3 months
    Infertility, after the 3rd injection à chance for infertility for 6-12 months. Are you going to plan to get pregnant in the next 1 year?

    Chance of pregnancy: 1 in 100 (?)
    If get pregnant, ­ ectopic pregnancy (still better than IUCD) because progesterone slows transport of egg + sperm on implant in uterus.

    Chance to get pregnant
    After 1st injection à fertility comes back in 3 months
    After 3rd injection à 6-12 months

    If I have DVT, can I use Depo Provera?
    Yes, it contains progesterone and not increase risk of DVT.
  29. OTD

    OTD Guest

    Paediatric questions


    “Always start with good news, tell bad news towards the end and then
    finish up with good newsâ€
    Should not say ‘it is serious disease’ in Paediatrics

    Relevant questions mean < 1 minute

    Mrs.Jones brings her son, 5 years old with a history of developing fever over the past 4 days. He has pain in the right leg, just below the knee. The boy has progressive developed a limp.
    Task: Relevant history
    Ask PE and Ix from the examiner
    Discuss the management with mum
    His brother kicked him at his legs few days ago while they played football at home. He complaints of pain, cannot sleep well. Before this problem started, he has been well.

    Focused History: trauma
    Infections: sore throat, skin infection, scratch mark
    Has he been well?
    ABO allergy: Has he had any allergic reaction to any
    Antibiotics?
    Any episodes of limping before?
    Physical exam: v/s, GA
    HEENT: any tonsil enlargement, redness, pharynx
    Leg: signs of inflammation, joint limitation, tender
    Skin: any lesions, wound, rash
    Investigations: FBE, CRP (and/or ESR), X-ray,
    Bone scan (confirmation test)
    +/- sepsis work up
    Treatment: Admit to the hospital
    IV line should be insert
    IV ABO commenced: Flucloxacillin
    >5 years old IV for 4-6 days then oral
    <5 years old IV for at least 21 days

    Hello Mrs.Jones, I’m Dr.Sira. What is your child’s name? (Jo) I understand that Jo has pain at his right leg with fever and now developing limping, is that correct? I would like to ask you several questions, regarding to his conditions.
    Did he have any trauma before the pain? (His brother kicked him few days ago while they played football together.)
    Had he complained pain after that straight away? (no, next morning)
    Did he start limping after that? (no, few days later) Has he ever had limping before? (no)
    Did he compliant sore throat or skin infection anywhere else? (no)
    So has he been well?
    Has he had any allergic reaction to anything before? (no)
    How about allergic reaction to any antibiotics or other medications? (no)

    May I examine the patients? (What do you want to do?)
    General appearance (normal), vital signs (temp 39) throat (normal)
    Heart and lungs are O.K? (yes) Abdomen, is there any mass? (no)
    Any lymph nodes enlargement? (no)
    I’ll go to look at the right leg, are there any signs of inflammation? Redness, swelling, warmness of the joint and affected area? (no)
    Is there any tenderness below the knee joint? (yes)
    How about range of motion? (the child denies to move his knee fully due to pain)

    I would like to do some investigation for Jo’s condition. I would send him to have an X-ray and take some blood sample from him.
    What is the result of an X-ray of the right leg? (normal)
    How about FBE result? (Hb is normal, leukocytosis with WBC 15,000)
    CRP (high, 60) ESR (not done)
    I would like to do a bone scan to confirm the diagnosis. (Bone scan confirms osteomyelitis)

    I’ll go back to explain to the mother.
    Mrs.Jones, from your explanation about Jo’s condition as well as my examination and investigation, I’m afraid to tell you that Jo is most likely to have a condition called ‘Acute osteomyelitis’, which is an infection of the bone. Have you ever heard about that? Osteomyelitis is an infection of the bone that caused by trauma or infection in somewhere else in the body and need to be treated by intravenous antibiotics and Jo has to be admitted into the hospital.
    Is it serious?
    It is not serious at the moment as we treat him in this early stage, the result would be good and he should do very well with the treatment.
    How long does he have to stay in the hospital?
    It depends on his response to the treatment. Normally, we give antibiotic injection to a child who is over 5 years old for about 4 to 6 days, if the child responses well, we can change to oral antibiotics. In Jo’s case, it might be about the same time but still it depends on his response.
    It is probably involved more bone scan during the treatment to see how the response is and orthopaedic consultation might be also involved.
    Are there any complications?
    Yes, septic arthritis might happen in some cases but as we start treatment early in Jo, it is less likely to happen to him
    I understand that it sounds to be serious to have intravenous antibiotics and be admitted. Don’t be worried too much at this stage, after the treatment starts, Jo should do very well.
    Do you have any other questions?

    A 4 years old boy, bed wetting at night. He had dry during daytime since he was 2.5 years old. Urine test is negative
    Task: Relevant history for 1 minute
    Explain to the mother and outline your management
    Growth and development is fine, height and weight are in the normal range
    FH: Father had the same problem when he was 6 years old

    History: FH
    Growth and development, is everything normal?
    Is he constipated?
    (Bully at school?)
    Management: Confirm that it is normal.
    Advice that he is too young for specific treatment and use of pull-up might be introduced

    Hello, I’m Dr.Sira, what’s your name? (Call me Mrs.Smith)
    I understand that you’re frustrated about your child’s bed wetting but the fact is he is 4 years old and it is normal. It is usually occurred in a deep sleep so he can’t help it. It is not his false and he shouldn’t be blamed. Normally, it tends to happen more in boy and it runs in the family. As you told me, his father had the same problem even when he was 6 years old. Don’t worry, about 50% of 3 years olds wet their pants as do 20% of 4 years old. The problem will usually reduce 10-15% each year old increase, so it will eventually go away.
    What should I do for him now?
    All right, you can try using a special absorbent pads beneath the bottom sheet rather than using a nappy and don’t punish him when he wets the bed. Do not wake him up at night to go to toilet, try to make him feel comfortable when he’s sleeping. You don’t have to stop him drinking after the evening meal and a night light might help if he wakes up and goes to toilet by himself. Another thing is make sure that he has a shower or bath before going to school.
    Can I use nappy?
    I don’t really recommend you to use nappy but if you really want, you can try pull-up nappy, which is easy for your boy to take it off if he goes to toilet at night.
    Are there any special treatments for this?
    There are several methods but the bed alarm system would be the most effective. There is a small bakelite chip that attached to the child’s briefs by a safety pin. A lead connects to the buzzer outside the bed, which makes a loud noise when urine is passed. The child would wake, switch off the buzzer and go to the toilet. However, this method works well in older children, especially from 7 years old so your child is too young for this. As I tell you, it is normal for your child’s age so no treatment is needed now.
    When should I consider bed-wetting as a problem?
    About 6 or 7 years old if regular bed-wetting still occurs and causes distress.

    A father who is a business banker, brings his 2.5 years old child to see you because his daughter losses appetite. She has 2 siblings, 10 and 12 years old, both of them are eating well. He’s worried that he didn’t take care of her very well.
    Task: Relevant history
    PE
    Management the case and explain to the father.

    History: Any other concerns? Family problem?
    Has the child been well?
    Growth and development?
    PE: GA, Growth chart, percentile of height and weight

    Hello, I’m Dr.Sira, what do you want me to call you? (Mr.Smith)
    All right, I understand that you concerns about your daughter’s appetite, what’s her name? (Lucy) Has she been well? (yes)
    Does she drink a lot of juice or milk? (no, she doesn’t drink or eat as much as she did)
    Can you remember her birth weight?
    What is her growth and development? (good)
    Is she constipated? (no)
    Do you know what she eats at the childcare? (not really)
    How does your wife feel about this problem?
    Do you have any other concerns?

    I’d like to examine the child. (What do you want to know?)
    GA (normal) weight and height and I would like to see the growth chart. (60 percentile for her age)
    Any other abnormal findings on examination? (no)

    I’ll then explain to the father and show him the growth chart.
    All right Mr.Smith, I understand that you concern about Lucy’s eating habit. However, let’s see from this growth chart, her growth and development is within normal range. And you can see from the normal pattern here, the growth rate slows down in 2nd year of life so they don’t need food as much as in the 1st year of life and drop in appetite as we call them ‘fuzzy eater’. As same as what happen with Lucy, she doesn’t want as much energy as when she was 1 so she loss her appetite as well. As long as her growth as development is still in a normal range, there is no need to be worried.
    What can I do for her?
    You can do many things such as allow her to eat what she likes and serve her small proportion, try to reduce your expectation. Don’t give her so much milk and juice and avoid argument over food. You might try to serve her some finger food, would be fun for both of you and give time to enjoy meal, don’t be hurry. Remember, a healthy child will eat when they are hungry and let her choose what she likes. Showing independency is important for toddler development as well.
    Can she have cereal for lunch? She seems to eat ‘Coco Pops’ a lot.
    Yes, she can as long as she wants to eat and she likes. Variety of food is not a big concern in her age. Do you still have any other concerns?

    Mother brings a 5 years old boy with complaints of periorbital oedema for 24 hours and decreased urine output. The child had “school sore†three weeks ago, which was treated with topical medications.
    Task: Take a relevant history from mother
    Ask the examiner for the finding and investigation results
    Discuss the management and prognosis with the mother

    Relevant history: Has he been well?
    What is the colour of the urine?
    Do you think he puts on weight or look a bit puffier than usual? Is there oedema somewhere else?
    Any other infections?
    Physical examination: GA, V/S (esp. BP), Body weight (increased?)
    HEENT: puffy eye
    Lungs: any crepitus
    Abdomen: any fluid
    Extremities: Pitting oedema
    Investigations: Urine examination (haematuria, proteinuria, specific gravity)
    Blood urea (increased)
    GABHS antigens
    Electrolyte, esp. K
    FBE +/-
    APSGN = discoloured urine + periorbital oedema + oliguria

    Hello Mrs.Jones, I’m Dr.Sira. I understand that your child is not well for 24 hours, apart from puffy eyes, do you notice oedema or swelling anywhere else on his body? (no)
    What is the colour of his urine? (darker)
    Do you feel he looks puffy or put on weight? (no)
    Has he been well before? (yes)

    I’d like to ask for examination findings. (What do you want to know?)
    GA (look sick), V/S BP (130/95) that’s high for his age
    HEENT (periorbital oedema) Lungs, any crepitus? (no)
    Abdomen, any oedema (no) Legs (slightly pitting oedema)

    I’d like to know the investigation results. (What do you want?)
    Urine examination (Proteinuria 1+, haematuria 3+) specific gravity (1.30) very concentrated
    FBE (normal) Blood urea (high) Blood electrolyte esp. K (upper normal limit)
    GABHS antigens (not done)

    I’ll then back to Mrs.Jones.
    Mrs.Jones, we found that your child has an inflammation of the kidney, which is related to the school sore that he had few weeks ago. I need to admit your child into the hospital, monitor his water work and treat the kidney inflammation. At the same time, I would suggest him to have bed rest, reduce salt and protein in his food as well as fluid restriction. We’ll monitor his blood pressure as well as his urine output. I’ll also give him diuretics, which will help lower his blood pressure as well as increase his urine output.
    Is it serious?
    Not with a proper treatment and usually it’s self-limiting. The prognosis is very good, about 95% of the affected child will recover completely.
    When he will recover?
    It might take several days but the resolution is variable. He should do well after we start the treatment.
    Does he need any antibiotic?
    Depends on his blood test result. If we can still find bacteria in his blood, I will start antibiotics, does he have any allergy to ABO? (no) Well, if there is no bacteria left, we don’t need ABO in his treatment.
    Will he get bad kidney in the future?
    Unlikely. As I told you this disease has very good prognosis, so don’t worry too much. He should do very well in few days.
    Are there any questions you would like to ask? Thanks.

    Father brought 3 years old with complaint of fever and bruising, you did a blood test on this child
    FBE shows decreased Hb, decreased WBC, decreased platelets, child’s mother is overseas at the moment.
    Discuss the result with the child’s father and advise him on the management.

    DDX is aplastic anemia and acute leukemia, have to do bone marrow biopsy to get definite diagnosis.

    Cause of aplastic anemia: Post-infection
    Drug
    Chemical substances

    Transfusion might be needed, depends on degree of anemia
    1st treatment is medication: steroid
    Erythropoietin
    Testosterone
    Spontaneous resolution happens in post-infection.
    Bone marrow transplantation is the last source

    Mother needs to come back, not for BM compatibility test, but as the child will go through treatment with uncertain prognosis, the child need support from both parents.

    5 years old child with recurrent otitis media, was treated with amoxicillin by your colleague. The child had ear ache 3 times in 6 weeks. The child also had snoring and mouth breathing history. His mother comes to you with another relapse. O/E tympanic membrane was bulging and red, child was febrile. Mother wants to know alternative treatments, surgery and medication.

    Task: Advise the mother about the treatment options
    No history taking or physical examination

    There are 2 problems in this child:
    Recurrent OM with ear pain
    Snoring and mouth breathing, might be chronic upper airway obstruction.
    Look at nose for allergic rhinitis
    Look at throat for tonsil and adenoid
    Have to r/o mastoiditis if any mastoid tenderness à CT scan and refer ENT
    Management is relief pain and management the chronic OM and chronic upper airway obstruction.

    Relief pain by simple analgesic (Paracetamol), might perform myringotomy ± tympanostomy tube. Treat infection by ABO then considering adenoidectomy ± tonsillectomy when the infection is subsided. Remember to check hearing test after infection is subsided.

    18 month-old Susan, had otitis media, treated by ceftriaxone for 1 week, comes to see you after 2 weeks.
    At 1st visit, she was irritated so you couldn’t examine her properly but you heard a murmur in the heart. Now, 2nd visit, Susan has no fever, murmur grade2/6, soft, mid-systolic, not radiating, no signs of heart failure. Her drum is not inflamed now.

    Task: Ask the examiner for cardiovascular findings
    Explain the mother about your finding
    (the murmur is grade 2 systolic murmur at left sternal border, decrease in inspiration and increase when lying down)

    Examination of heart
    Cyanosis
    Dyspneoa
    Tachycardia
    BP
    Is the pulse normal? Character and time
    Any displaced apex?
    Is there any added sound, ejection click?
    Any split S2
    Where is the murmur conducted?
    Increase or decrease in inspiration, lying down, sitting forward
    Characteristic of murmur
    Time of murmur

    Comparison between VSD and innocent murmur
    Innocent murmur
    · Acyanosis
    · ¯ in inspiration
    · ­ when lying down
    · no action require, just reassurance that it can be heard when the child has fever or sick and will disappear in high school age, no treatment required.
    VSD
    · pansystolic murmur
    · conduct in axilla
    · full pulse
    · heard at the back, thrill at substernal edge
    · High pitch murmur
    · If apex beat is shift, full pulse, it is significant shunt and load S2 shows pulmonary hypertension
    · Need ABO prophylaxis for procedure and need refer to paediatric cardiologist.

    Apart from reassurance mother, have to check up hearing 3 months (audiometry).

    A 12 years old girl, has her first period, last 10 days.

    Task: Take a relevant history
    Ask the physical finding from the examiner
    Outline your management on this girl

    Questions to ask:
    Has the child been well?
    How many pads per day?
    How old was the mother’s menarche?
    Any growth spurt or pubic hair?
    Associated symptoms: anemia, cramping pain

    Might talk to mother that she is now starting her period, you should advise about sexual education. Do you want to do that by yourself or you want me to do that?

    If period continues, use a lot of pads and having signs of anemia à investigation
    If continue for 3 weeks, start investigation

    In this case, if the period starts to be less and less, use less pads, no signs of anemia, can advise and follow up in 1 week.

    8 months old baby boy, brought by parents as he has fever and irritability and had previously 3 episodes of otitis media. Mother is upset because she has to take time off from work often.
    O/E: red bulging tympanic membrane
    Tonsil is slightly enlarged and inflamed

    Task: Ask clarify questions
    Discuss management

    Clarify questions
    Is the child in the childcare?
    Is the baby premature?
    FH of allergy or frequent infection or immunological deficiency

    Supperative OM, breast feeding would be protective.
    ABO for 2 week + analgesic
    F/U 2 week to make sure that no effusion, and do hearing test in 6 weeks
    Might need myringotomy if fluid is sustained and impaired hearing, have to consult ENT for this and might have tympanostomy tube for drainage

    Also think about IgG deficiency
    Might start ABO prophylaxis for prevent the recurrent and if persistent nasal obstruction, might be sinusitis as well.
    If mother is too busy, discuss social welfare.

    Give Amoxy+Panadol+nasal spray, tell mother the child is likely to be better in 12-24 hours, bring him back tomorrow. If still not improve, consider drain.

    11 month-old infant, referred by maternal child nurse because she fails the hearing test but the mother doesn’t think that the baby has hearing loss.
    Task: Brief relevant history
    Relevant PE and Ix from the examiner
    Talk to the parents about Dx and Mx
    No FH of hearing loss, normal pregnancy, term and normal delivery. The baby had a hearing test at 8 months, it was abnormal so that repeat again at 11 months. Milestones are normal.
    PH: 2 ear infections at 7 months (right) and then 6 weeks later (left)
    PE: Ears – intact tympanic membrane but Rt. Is red and dull

    Questions to ask:
    Pregnancy history: any infections such as rubella
    FH of hearing loss
    Development: When did the baby bumble? What make you think that the baby can hear you? When did the baby response to your voice?
    Did the baby have any antibiotics? What were they? (Gentamicin for UTI is ototoxic)
    Is there any mouth breathing?

    Physical examination:
    Head contour and size: microcephaly from Rubella
    Throat: cleft palate? Tonsil?
    Ears: is the formation normal? Is TM mobile?

    Differential diagnosis:
    Acquired hearing loss
    Permanent
    Temporary: Post OM (glue ear) * most common
    Major cognitive problem: Mental retard
    TORCH eg. Rubella

    Management
    Send the baby to do audiometry by 2-3 weeks, by the time to get the result, the baby might get better if it’s temporary.
    Refer to ENT surgeon if the anomaly exist
    No role for ABO

    5 years old boy soiling his pants for the last 6 weeks. His friends at school tease him and called him ‘stinky’.
    Task: Relevant history and PE from the examiner
    Discuss management with the mother

    Start toilet training at 2.5 year

    Questions to ask:
    How often he passes his bowel?
    Has he been constipated?
    Is the stool hard?
    FH of constipation
    Diet history: junk food, high fatty food

    Physical examination:
    Abdomen: any distension? Fecal lump?
    Anal area: skin tag, anal fissure, any evidence of trauma (child abuse), sign of spina occulta

    Diagnosis: fecal impaction with diarrhea incontinence

    Treatment:
    · Empty bowel: mycolax enema
    Stool softener
    Laxative (Parachoc, Senokort)
    · Regular the bowel à 2-3 times a day, 5 min
    · Good diet à high fibre, more fluid
    · Follow up 1 week
    · Investigation is not necessary but might do abdominal X-ray

    Parents brought a 3 years old kid with recent URTI 10 days ago. The child developed purpuric rash (picture of a bottom with rash), abdominal pain and ankle swelling.
    Task: Diagnosis (No history, findings, investigation)
    Management
    (May 2005, Melbourne)

    HSP: Reaction of the immune system to the blood vessel and it is temporary, nearly all of them make a complete recovery.

    Need to admit the child to observe urine output, BP and complication such as:
    · Intussusception: crampy abdominal pain, vomiting
    · Arthritis
    · Very severe rash
    · Oliguria, HT and then ARF but it is uncommon. If happens, treat by furosemide
    In mild situation à no need to admit
    Give steroid, the child would be better in 24 hours, admit for 1-2 days then if gets better, discharge and continue steroid for couple of weeks.

    Is it serious?
    No, it’s not serious at the moment and we start treatment to prevent it becomes serious. Nearly every child has complete recovery.

    ^^^^^^^^^^^^^^^^^^^^^^^^^

    Questions to ask:
    Has the child been well before? Has he been tired or paled?
    Do you feel the child has fever or hot?
    Does he have nausea or vomiting?
    Does he get bruise easily?
    Does he compliant any joint pain?
    What is the colour of his stool? (melena?)
    Is there any blood disorder in the family?

    Physical examination:
    GA: look sick?
    Vital signs: fever?
    Heart: murmur?
    Abdomen: tender, rebound?
    Extremities: oedema? Rash? Joint swelling? Ankle swellingà inflammation or oedema?
    Other areas of bruise, purpuric rash?

    Investigation:
    FBE: anemia, thrombocytopenia?
    Bleeding time, coagulation
    UA: haematuria, proteinuria
    Renal function: urea/creatinine, urine protein estimation

    Treatment
    No specific treatment, mostly self-limiting within 1 to 4 week, generally excellent prognosis
    Supportive: rest and analgesia
    Corticosteroids: may reduce the duration of abdominal pain but have to exclude complication such as intussusception, appendicitis, bleeding
    Others: rare
    o Immunosuppression or plasmapheresis and antihypertensive drug might be used in severe renal impairement
    o Surgical intervention if appendicitis or intussusception occur.

    Differential diagnosis:
    HSP (Henoch-Schonlein Purpura)
    Meningococcal septicemia à same rash but the child looks sick with high fever
    Leukemia à pallor and tiredness
    ITP à thrombocytopenia, purpura related to mild trauma
    Viral infection
    Child abuse

    (GP p.291, 408; OHCS p.275; Paed. Handbook p.515, 262)

    23 year-old primipara, a child developed jaundice in the first 24 hours, billirubin 244/6. The child is otherwise well, feeding well and alert. Mother wants to go home ASAP.
    Task: Clarify questions
    Ddx newborn jaundice
    Explain to mother and decide on management.
    (Feb 2004, Melbourne)

    Questions to ask:
    Is the baby term?
    What is the mother’s blood group? (O+) What is the baby’s blood group? (A+)
    Is the baby anemic? (ask for FBE)
    What is the coomb’s test result? (positive)

    Jaundice in the first 24 hours is abnormal until proven otherwise.

    My baby looks normal, can we go home?
    I’m afraid to say that your baby can’t go home right now, I need to admit the baby to make sure that the baby stay well and follow up the billirubin level. It’s higher than normal now so we’ll put him/her under UV light and check the billirubin again. Most of the time it gets better but if not, we have to do a blood transfusion for him/her to reduce this billirubin level.

    It sounds serious?
    It’s not serious at the moment, we treat to prevent it becomes serious in the future.

    What is the cause?
    What happen is your blood group and your baby’s blood group is different and this cause destruction of the RBC. The RBC is broken down so the baby turns yellow.

    6 years old boy brought by his mother to you, GP, as he was reported by teacher as having difficulties because of disruptive behaviour.
    Task: Take relevant history
    Make a diagnosis and outline your management
    (April 2005, Adelaide)

    Questions to ask:
    Development history: talking, walking (ADHD à walk fast, talk slow)
    Learning achievement
    FH
    Normal pregnancy
    Hearing or vision impairement
    Family problem: alcohol

    Physical examination:
    GA: clumsy, untidy hand-writing

    It is not clear to me that he is a naughty boy or he had problem with learning and concentration or ADHD. I need more information from school, school report. There is a checklist for diagnosis of ADHD (both parents and school).

    If it’s ADHD, refer to child psychiatrist to arrange behaviour strategies but it’s rare to diagnose ADHD at the 1st visit., need another appointment.

    Ddx:
    · Naughty boy
    · Deaf
    · Conduct disorder
    · Depression
    · Child abuse

    ADHD sometimes associated with obstructive sleep apnea.

    You are an intern in ED. A 4/12 old baby brought by very anxious mother to the hospital for few hours of becoming drowsy, not eating and drinking well. No wet nappies for few hours.
    Task: Ask clarified questions and findings from the examiner
    Management
    (May 2004, Adelaide)

    Questions to ask:
    Has the child been well?
    Is he/she alert or smile?
    Did he/she have diarrhea, vomiting, fever, rash, flu-like symptoms?

    Findings:
    GA: (drowsy)
    V/S: Esp. BP, temp, PR, RR
    Signs of dehydration, fontanelle (a bit depressed)
    HEET*: Ear & throat are very important!!
    Lungs, abdomen just in general
    Stiff neck (if negative, not exclude meningitis)

    Management is ADMIT and SEPTIC WORK-UP
    If urine is +ve à no need to do lumbar puncture
    If the child is very sick à LP is indicated

    A 2 years old girl, presents with just nocturnal cough for few months
    Task: Take relevant history from the examiner
    Ask relevant findings from the examiner
    Talk about diagnosis and management with the mother
    (May 2004, Adelaide)

    Questions to ask:
    Other allergies
    Blocked nose, runny nose
    Mouth breathing, snore at night
    FH
    Does anyone smoke in the house?
    Have the child had bronchiolitis or been admitted in the hospital?
    Was there a fever at that time?
    Does she cough when running around?

    Finding:
    Is she failure to thrive?
    Ear, throat, nose (swelling of the tuberlae, tonsil a bit enlarged
    Lungs: Hyperinflation, rib retraction? Prolonged expiration?

    DDX: Asthma
    Post-nasal drip

    Management:
    · Asthma is intermittent and reversible airway obstruction.
    · Trial of asthma treatment à Ventolin when having cough
    · If stop the cough à Dx Asthma and can use preventer
    · If < 1 year, there are not so many smooth muscles, so no bronchospasm, called ‘bronchiolitis’.

    A 7 year-old child brought by ambulance, was observed fitting in school. He is quite O.K. now but he has wetty pants.
    Task: Relevant questions and findings
    Explain to father and management

    Questions to ask:
    Has he had this before?
    Development?
    Did he loss consciousness?
    Jerk à generalized or partial
    FH (uncle has epilepsy)
    Any vomiting and/or fever?
    PH of febrile convulsion?

    Findings:
    Cutaneous signs:
    o neurofibroma (CafÈ au lait spot)
    o Hemangioma (redness on face)
    Neurological signs esp. motor, power, reflex**

    Ix: EEC

    It’s probably that your son has epilepsy. Seizure happened due to the part of the brain is hyperactive and affects the whole brain. We’ll do a brain wave recording to see whether there is abnormal brain wave or not.

    No medication after the 1st episode
    F/U clinical signs 2-3 months
    A 2 years old female child, who was normal delivered at term, has been found to stop breathing and then fitting, precipitating by tantrum. EEG is normal (done because she had jerk of limbs at the end of episode)
    a. Explain to the parents

    DDX: Breath Holding attack`
    Iron def. Anaemia (if pale > blue, Hx of cow milk)

    EEC: reassure but not exclude epilepsy
    If pallor, might do ECG and FBE

    Management:
    Re-emphasize that it’s not harmful
    Ignore, walk away when she has tantrum
    Shouldn’t say ‘try to avoid situation’, it’s not practical. Must stress on stressing that it’s not harmful

    You are a Paediatric resident in RCH, a 12-month old girl has been admitted 1-2 days due to diarrhea for few days ago with history of diarrhea 10 mothins/day with 5% weight loss.
    b. Ask questions and finding from the examiner
    c. Discuss management and explain to the parents

    She has blood and mucus in stool, 1-2 vomiting and temperature < 38, ¯ urine output,
    Parents run mild bar.
    Findings:
    Dry, Fontanelle – not sure
    PR: rapid, BP 75/50, ~4% dehydration
    Abdomen: no mass, soft, no anal excoriation

    Questions to ask:
    Vomiting
    Blood-mucus in stool?
    Introduction of new food, cow milk, solid or just breast-feeding?
    Occupation of the parents

    Physical findings and Ix:
    Signs of dehydration
    Abdomen à any distention?
    Stool exam and culture**

    Management in this patient
    · Blood + mucus in stool à bacterial colitis à always send for stool microscopic and culture
    Oral rehydration
    a. Drink more
    b. Add gastrolyte or if can’t drink, try
    c. NG feeding by bolus of gastrolyte~10% of fluid requirement (5-10 ml/kg)
    Lactose-free formula
    Notify health department because parents are carrier à need treatment by ABO (?) + can’t handle food until treated. Health department will follow up and arrange for that.

    This case is more likely to be Salmonella than Shigella (more acute and more blood) and both of them are self-limited; no ABO
    If high fever à ABO

    Acute diarrhea, the most important is gastrolyte and oral hydration

    Mrs. Brown bring a 3 year-old son, has been in good health, attended childcare. He has several loose watery motions. From his welfare record, > 50 percentile of height and weight. Normally, he drinks 500 ml cow milk/day, now 300 ml/day. PE is normal. No history taking.
    d. Tell mother what the problem is
    e. Management

    It appears that your child has gastroenteritis caused by viral infection, he might probably picked up from the childcare. It is very common condition and he’s going to be alright, particularly his drinking is OK. What we need to do is stop the milk for 24 hour to rest the gut and allow to recovery digestive ability the gut to be back in normal functions. I’ll give him gastrolyte which helps turn off the diarrhea and feed him more fluid to correct the dehydration.

    Main management:
    Reassure that it’s common and not dangerous
    Stop milk for 24 hours and replace by fluid rehydration
    Gastrolyte

    A 4 month-old baby has been well, growth and development is good, now presenting with low-grade fever, runny nose and coughing. Father’s father died of pneumonia and worried about his son. O/E: noisy sounds throughout the chest. Baby looks well, not cyanosed. Last few days, not feeding well and dry nappy.
    f. Relevant history and finding from the examiners
    g. Advice father about diagnosis and management

    Questions to ask:
    Signs of dehydration
    Capillary return
    Find out how bad: hyperinflation, RR, nasal flaring, chest sucking, cyanosis during feeding? à to find out if the baby should be admitted or not
    Sleeping well? If hypoxia à irritable

    Don’t ask about prematurity (Hx told that has been well), breast-feeding or rash à irrelevant

    If this child is moderate to severe so management would be:
    Admit
    Oxygen
    Observe feeding if not good à NG feed à IV

    If mild, no need to admit but if <6 wk, admit

    When father asks about pneumonia as his brother died from pneumonia, ask about
    What happened at that time?
    What is the cause of pneumonia? Cystic fibrosis? (Victorian kids have screening test at birth so no need to worry)
    How old was he? How many years ago?
    Has he been sick before? (might be immunocompromised host)

    DDX Bronchiolitis VS Pneumonia
    Rhinitis, cough esp. cough ¯
    Signs of airway obstruction present ¯
    Temperature low high
    GA better more severe
    Breathing noisy RR: tachypnea, grunting
    Hyperinflation present absent
    Chest exam noisy chest quiet chest
    It’s not necessary to take CXR
    Do CXR when the S/S is not typical and if the baby doesn’t get better.

    If bronchiolitis can’t get better à think about cystic fibrosis

    8 year-old Bill has several episodes of ‘switching off’ in the class for few weeks. Mother brings him to see GP
    Task: Questions and findings from the examiner
    Tell mother about Dx and management

    Mother’s sister has similar problem, normal development, good in school, PE: well

    Questions to ask:
    Previous history: delayed development, growth, school performance, mental retard?
    FH of epilepsy, other episodes of generalized seizure
    Previous episode of epilepsy
    Loss of consciousness or fell down

    Finding:
    Normally can’t find anything

    In 8 years old DDX is vago-vagal spasm and small percentage can have generalized seizure as well.

    If 3 years old, is more likely to be generalized epilepsy with absence and neurological deficit
    DDX: Breath holding attack
    Cardio-vascular event
    Mental retardation
    Day dreaming

    Management:
    Na valproate: it’s good to prevent developing generalized seizure

    A 4.5 year-old child, seeing you in GP clinic with her father. She’s been previously well but been unwell for the last 4 days. Her feeding is not good, irritable and becomes drowsy in the last 24 hours with presence of maculo-papular rash on the trunk. She is dehydrated with temperature of 40 degree. No neck stiffness and BP is 90/50 mmHg.
    h. Relevant question
    i. Discuss management

    DDX: Septicaemia
    Viral exanthem
    Kawasaki disease: strawberry tongue, LN, exudates on throat, cardiac finding
    Scarlet fever: sand-feeling rash (?)

    Management is
    · Explain that your child has high fever and look not good, more likely to be bacterial infection or severe viral infection.
    · A shot of ABO (Ceftriaxone) IM or IV, then refer to the hospital by ambulance

    Sick kid, drowsy, high fever:
    Bacterial infection
    Severe viral infection, Kawasaki disease, Roseolla infantum (?)

    If thinking about severe septicaemia or if haemorrhagic rash (meningococcal) à give a shot of ABO and refer to ED by ambulance

    A 8-year old girl, brought to you by her mother, concerning that she is the shortest in the class, otherwise well and healthy. Her birth weight is 2.5 kg.
    j. History and findings from examiner
    k. Dx or DDX and explain

    Questions to ask:
    Growth chart, development
    Height and weight of parents and sibling

    Physical examination:
    Percentile in the growth chart and height for age
    Stigmata of Turner’s syndrome

    Investigation:
    Bone age*: left wrist X-ray > 20 bones
    Chromosome study* (Short stature in girls is Turner’s syndrome, unless proven otherwise**)
    TFT
    FBE, ESR, U&E, LFT
    GH

    DDX: Turner’s syndrome
    Hypothyroidism
    Familial short stature (FH)
    Constitutional delay in maturation
    Might be Coeliac disease, Crohn’s disease (rare)

    Short stature counseling: Height is not the main issue in life. Nothing’s wrong with short stature. There are many things such as how good person she is, how honest she is, these are more important than her height.

    Turner’s syndrome: Condition in which one of X chromosome is not normal. Do you know what is chromosome? The X chromosome is one of the sex chromosomes, which are X and Y, in a normal girl, there are 2 X chromosomes. Turner’s syndrome, which is one of the causes of short stature, in this case the girl has one of the X chromosome abnormal. (can be XO, XX abnormal, XXX)

    In Turner’s syndrome, it’s less likely that the girl will have period, might need HRT, and might adopt children in the future. Stem cell or ovarian transplantation is still on-going research and might help.à Reproductive therapy that might help, it’s not impossible.

    Mrs. Smith has just separated from her husband, comes to see you with suspicion that her 2 year-old daughter might be sexual abuse by her new partner. The child doesn’t want to go back to her father’s house.
    l. Management

    The main thing to do is doing nothing! Shouldn’t contaminate the history by asking the child questions or do physical examination. These things need to be done by expert (Gatehouse Centre)

    Ask general questions to the child, not sexual abused questions and do general PE, including find the evidence of possible child abused.
    Would you like to stay with your dad? If not, why don’t you like your dad?

    Contact child protection or human service department.

    I understand that it’s very upsetting to you. This thing is beyond my responsibility, I’d refer your child to Gatehouse centre. People there are expert in child sexual abused, they will take sample from you child and find evidence to prove your suspicion. They will take care of your concern and I’ll follow up you with the Gatehouse centre after everything is done.

    Should I contact the police?
    Not necessary now, the Gatehouse centre will take care of that and if need to, they’ll arrange for you.

    If the child doesn’t want to stay with her father and cannot isolate her from her step-father à can admit the child for protection. Anyway, the first thing is refer to Gatehouse centre and they have their guideline for this.

    If it’s child abused case, GP or HMO can do PE and record on the chart à bruise, anal excoriation.

    You are a local GP, 150 km from the nearest Paediatric Centre. The lady brings her daughter, 9, who has been diagnosed with DM type1 for 18 months. You’ve been asked to continue Mx for her. No further Hx.

    Management:
    Check BS record book
    Check HbA1C every 3 months
    Check the injection site
    Check blood pressure
    Check Urine sugar
    Follow up her with endocrinologist, dietician and children diabetic clinic at least once a year
    Other issues:
    a. Sick Mx
    b. Exercise
    c. Travel Mx
    d. Eating à don’t skip meal
    e. Review school report

    Ask mum if she’s coping alright
    Complication review from 10 or 12 years old

    A 4 year-old boy got bee sting, presents with wheezing and hypotension.
    m. Management

    Management:
    Oxygen
    Adrenaline IM or IV
    Antihistamine/steroid
    Salbutamol NB

    Advice to the father
    You child has severe allergic reaction to bee sting.
    Advice Epipen for next attack
    Antihistamine tablet if mild reaction
    Find the allergen
    Refer to Paediatric immonologist

    Mrs. Brown brings her 5 years old girl with s/s of dysuria and going to toilet many times. About 6 months ago she had the same symptom and got better. She also noticed greenish d/c from her child’s vagina.
    n. Clarify questions and relevant PE from the examiner
    o. Explain Dx and Mx

    Ddx: Vulvo-vaginitis
    UTI
    FB (profused, bloody d/c, foul smell)
    Sexual abuse
    Pin worm
    Constipation

    Questions:
    Is she constipated?
    PH of UIT
    FH of urinary tract abnormality, FB anywhere else
    Amount of d/c, smelly?
    Does she scratch at night-time?
    Hx of eczema
    PE:
    GA, V/S (temp)
    Abdomen
    Genital area: signs of irritation, trauma
    D/c: colour, amount, smell

    You child has a condition what we called ‘vulvovaginitis’, have you heard about that? It’s an inflammation of the genital area. Also we need to exclude the infection of the urinary tract by testing her urine sample. (mid stream urine)

    How can it happen?
    The skin of the girl in her age is very thin and sensitive to many irritants such as soap, detergent, synthetic clothes. Wetness of the area and poor hygiene can also cause this. Improper toilet habit might be a cause as well. The toilet is usually too high for the girls in this age so the way she sits causing the urine goes back to the genital area and wet her panties.

    Mx:
    Supervised toilet habit: might change to sit facing the toilet
    Dry the area
    Zinc-based cream might help, Ergoderm

    If the problem is still persist, come back to see me in 3 days. Pamphlet & F/U

    Mrs. Papo.. (Mediterranean name) brings her 4 years old boy who is a little bit pale. FBE shows MCMC, Hb is 10.5. Iron study shows normal level of ferritin and iron.
    p. Explain Dx
    q. Mx and talk about relevant issue to the mother

    1st issue is the right Dx à Thal minor
    · Explain about gene
    · Need 2 abnormal genes to have disease
    If 1 gene is abnormal à Thal minor
    If 2 genes if abnormal à Thal major
    If parents has thal minor (both) à chance of having 2 abnormal genes
    2nd issue is the right conclusion à confirm by testing
    · Child’s blood or
    · Parents’ blood
    3rd issue is the clinical symptoms of the child
    · No symptoms, just a little bit decreased Hb
    4th issue is genetic implication:
    · Other family members
    · If wants more kids, there is a risk and need to be checked

    Another cause might be lead poisoning
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    OTD Guest

    PERTH 28 Oct 2006 OSCE QUESTIONS

    1 . 23 yr old woman,husband away on outstation trip. Just delivered her first child. You have examined him - he has epicanthic fold, hypotonia and you notice a gap between his first & second toe. You suspect that the baby has Down syndrome. Explain to the mum and answer any questions she may have.

    2. 28 yr female 32 weeks pregnant. She is a front seat passenger in a car that was involved in an accident. She has abdominal tenderness but is able to sit up and talk to you. Take relevant history, ask examiner about her examination findings and explain your diagnosis and management plan to patient.

    3. 32 weeks primigravid with breech presentation on routine examination. Talk to patient ,take brief focussed history and explain to the patient your management.

    4. 2 year old boy (Jamie) has jammed his hand in the car door. He cried for sometime and then turned blue and his hand twitched for few seconds. His concerned father is there in ED talk to him. Please take a relevant history and explain your diagnosis and further management.

    5. 3 year old girl(Lisa) with snoring and disturbed sleep at night. Frequent middle ear infections .Losing weight. O/E: Irritable,enlarged tonsils and white retracted tympanic membrane. Your task: Talk to her mum and explain your management plan to her.

    6. 18 year university student come to you(a general practitioner at the Student HealthService) for a prescription of oral contraceptive pills. Take relevant history and explain to her how to take oral contraception(don’t forget 7 day rule)

    7.Photo of right leg venous ulcer. Talk to the patient. History – fractured leg 20 yrs ago. Had surgery & developed blood clots in leg. Needed injections on belly to thin blood. Also well-controlled diabetes. Advice - your management.

    8. 65 yr happily married in Orthopaedic ward for after total knee replacement surgery. Was cheerful in evening though confused you for the consultant. Visited by wife and he became aggressive and accused her of having an affir with his best friend. Quite abusive ,restless and aggressive. Your registrar is busy in theatre and has asked the nurses to give 5mg of olanzepine wafer and to call you(the orthopaedic resident) . Take relevant history and perform relevant examination. And order any necessary investigation. Answer any questions from examiner.
    (Need to exclude hypoxia – pulmonary embolism, pneumothorax, fat embolism)

    9. Photo of left neck swelling(supraclavicular).Take history and give differential diagnosis to examiner. Ask examiner for any relevant clinical examination findings and explain your management plan to the patient. Order any investigation you would like to confirm your diagnosis.

    10. 62 year old with chest discomfort a few days ago. ECG normal at that time but you organize a stress ECG and the results have come back to you showing ST segment changes in anterior limb leads. Patient lives in country 2hrs from nearest hospital. Your task would be to manage him.

    11. Lady in 30’s Ht 175cm and Wt 95kg. Experienced shortness of breathing at work yesterday. Now comes to see you (her GP). Take relevant history and manage.
    (Need to exclude pulmonary embolism)

    12. Lady in 30’s comes to you complaining of SOB and insomnia. You have investigated her - ECG ,bloods (eg thyroid function test, Hb) - everything is normal. You suspect that she has Gen Anxiety disorder. Talk to patient about the diagnosis and management
    13. 24 year has just donated blood. You are her GP. She has been contacted by the Blood Bank and informed that she is Hepatitis C positive and has been asked to see you her GP. Advice her and answer any questions she may have.

    14. 20 yr with abdominal pain(right sided),vomited twice with pain but pain decreased now. Still uncomfortable. Ask relevant findings from examiner and answer any questions including investigation and management plan.

    15. 60 year man with pain on chewing and headache on right side of head You are suspecting temporal arteritis. Explain to patient any further investigation you would like her to have, your treatment and any referral you would make.

    16. University student presents with fever for 2 weeks and feeling very tired. O/E you find enlarged and inflamed tonsils. Take relevant history ask examination finding from examiner and explain the diagnosis and management plan to patient.
    (Infectious mononucleosis/Glandular fever)
  31. OTD

    OTD Guest

    . Mrs. Smith has just separated from her husband, comes to see you with suspicion that her 2 year-old daughter might be sexually abused by her new partner. The child doesn’t want to go back to her father’s house.
    Task : Management

    The main thing to do is doing nothing! Shouldn’t contaminate the history by asking the child questions or do physical examination. These things need to be done by expert (Gatehouse Centre)

    Ask general questions to the child, not sexual abused questions and do general PE, including find the evidence of possible child abused.
    Would you like to stay with your dad? If not, why don’t you like your dad?

    Contact child protection or human service department.

    I understand that it’s very upsetting to you. This thing is beyond my responsibility, I’d refer your child to Gatehouse centre. People there are expert in child sexual abuse, they will take sample from you child and find evidence to prove your suspicion. They will take care of your concern and I’ll follow up you with the Gatehouse centre after everything is done.

    Should I contact the police?
    Not necessary now, the Gatehouse centre will take care of that and if need to, they’ll arrange for you.

    If the child doesn’t want to stay with her father and cannot isolate her from her step-father à can admit the child for protection. Anyway, the first thing is refer to Gatehouse centre and they have their guideline for this.

    If it’s a child abuse case, GP or HMO can do PE and record on the chart à bruise, anal excoriation.
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    OTD Guest

    You are a local GP, 150 km from the nearest Paediatric Centre. The lady brings her daughter, 9, who has been diagnosed with DM type1 for 18 months. You’ve been asked to continue Mx for her. No further Hx.
    Task: Talk to the mother about your management

    Management:
    a. Check BS record book
    Check HbA1C every 3 months
    Check the injection site
    Check blood pressure
    Check Urine sugar
    Ensure follow up with endocrinologist, dietician and children diabetic clinic at least once a year
    Other issues:
    -Sick Mx
    -Exercise
    -Travel Mx
    -Eating à don’t skip meal
    -Review school report

    Ask mum if she’s coping alright
    Eye, heart and kidney complications: annual review from 10 or 12 years old
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    OTD Guest

    Father of a 3 wk old child comes to you as child is vomiting profusely since last 2 days. No diarrhea. The father says ‘vomit went everywhere’. The baby is on breast milk and feeds well. O/E: baby looks well, hydration good, v/s is given (all normal). Giant peristaltic waves seen on the abdomen. No mass felt.
    Task: Explain to the father what the problem is.
    No further history to be taken

    If can ask questions: Questions to ask:
    Is there any bile in vomitus?
    How far is the vomiting?
    Is the child febrile? à meningitis, UTI
    Gastro-esophageal reflux symptoms
    Time of vomiting after feeding

    Congenital pyloric stenosis
    · 2-8 weeks after birth
    · As stomach becomes bigger, the vomiting is more severe and more volume.

    Complication of pyloric stenosis
    Dehydration
    Hypokalaemia
    Alkalosis

    I’d like to do investigation to confirm my diagnosis.
    U/S to see severity of the stenosis
    U&E to see dehydration and electrolyte imbalance

    Your child has a condition called “pyloric stenosis”, (draw a diagram) this part of the stomach has a thickened wall and slows down the food.

    The treatment is a simple operation (pyloromyotomy) to make this site bigger and the successful rate is high. Your child will grow normally and everything will be normal. We need to refer your child to the surgeon as soon as possible.

    Does he have to have an operation now?
    The surgeon will assess his condition and decide whether he should have an operation now or later. The time of the operation depends on surgical team.

    Treatment:
    Admit the child
    IV (might need NSS + KCl)
    Consult surgery
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    OTD Guest

    4. Mr. Graham a 50 yr old man comes to ED, complaining of pain in his lumbar region for 3 days. He believes it may be spinal in origin. The pain became so severe 2 hours ago and was not settling. The nurse gave him some pain reliever and you are called to see him.
    Task: Take a history
    Tell the examiner what investigation you want to do.
    Explain the condition and management to the patient

    Pain occurred 3 times before for about 1 week. Father has stone but not sure where. His water work is smelly, thick color, no stone passing. He drinks occasionally and smokes 5-10/day for 20 years.
    Full ward test: Protein + RBC
    Microscopy:
    Blood U&E, Cr, uric acid – normal
    Plain KUB: calcification 1 cm at lower 1/3 of the ureter with some
    Dilatation.
    U/S: Kidney size is normal, no stone, no dilated calyx.

    Questions to ask:
    Pain: site, size, radiation, relieved by, aggravated by, associated symptoms.
    Any temperature
    Trauma or lifting
    1st episode?
    History of sciatica
    Major health problem, any stone before, job – sitting all the time
    Fluid intake
    PH, FH, Medication, Allergy, operation

    Investigation:
    85% of stones are radio-opaque
    Urine full ward test à if +ve then MSU microscopy
    Blood test is not really necessary
    Plain KUB
    Renal U/S to see kidney function, anatomy, size, dilatation
    Abdomen CT scan if can’t see stone from above tests

    DDX:
    · Stone
    · Sciatica
    · Rib fracture
    · Gallstones if right side
    · Pyelonephritis if fever

    We got the result of your test & found a stone there (draw a diagram), that’s why you feel pain. This stone moves and irritates the ureter so there is RBC in the urine.

    It’s 1 cm, and too big to pass out by itself so I need to admit you and have either open surgery or laparoscopic surgery. I need to talk to the surgical urologist to consider taking it out.

    It might be the previous stone that you had, fortunately, we found it early and kidney is not affected yet. To prevent further attacks, I suggest you to drink plenty of water.

    Can I leave it there?
    If left there à causes pain and affects your health and renal function: such as hydronephrosis.

    If < 4 or 5 mm à may pass, ask patient to pass urine using mesh to collect stone. If pass, plain KUB to see again.

    Surgery:
    · Endoscopy (cystoscopy with basket) if < 5 mm and < 5 cm from cysto-ureteric junction
    · Shock wave lithotripsy
    · Open surgery
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    OTD Guest

    Magi, a 32 yr old woman, comes to see you complaining of feeling anxious and irritable 1 week before her period, resulting in her getting mood change from happy to miserable in a short time which leads to getting short tempered with work colleagues and family members.
    Task: Take further relevant history
    Manage the condition

    The symptoms started a few years ago, no drinking and no smoking. Her period is regular and she had tubal ligation many years ago.
    Questions to ask:
    Pills, contraception, pap smear
    Surgery à ? tubal ligation
    Menstrual history
    Life style: job, marriage problem?

    Premenstrual syndrome caused by hormonal change and busy life-style.

    Conservative:
    Pamphlet about PMS
    Simple change in diet:
    o ­ Fluid and vegetable
    o ¯ Caffeine
    Relaxation technique
    Talk to husband and bring him next time, I can explain your condition to him.
    Try to have a good nights sleep
    Go for a walk
    Keep diary for 3 months (1 week before period and disappear in the 1st day of bleeding is confirmed PMS)

    Medication: (over-the-counter)
    Vitamin B6 50-100 mg everyday for 3 months then only 2nd half of the cycle or regularly.
    Evening Primrose oil 400 mg on day 12 until 1st day of bleeding for 6 months.
    OCP: No need in this case as she had tubal ligation. It’s good for control of symptoms and contraception at the same time, SE > benefit for her.
    Mefenamic acid (Ponstan)
    If severe PMS and failed other methods à can give anti-depressant (last source)
    Am I having early premenopause?
    No, you are not as your period is quite regular. This is PMS.
  36. OTD

    OTD Guest

    A midwife calls you to see a 38 yr old G6P4 woman, who has been in labor for 12 hours. You rush to her room and find that the third stage of labor has just been completed but she has had per vaginal loss of about 1.5 liter of blood.
    Task: Give your Diagnosis
    Manage the case

    CALL FOR HELP
    ABC
    2 IV cannula
    FBE, GM 4-6 units, U&E, coagulation and LFT

    When she’s stable, find the source of bleeding
    Look at placenta à complete?
    Uterine palpation to see if uterus contracted, if the bladder is full à empty and do another uterine palpation then
    Bimanual uterine massage.
    IV syntocinon then check uterus and check placenta. If still bleeding, go to EUA
    EUA (Examination under GA) by Sim’s speculum if no tear, then
    Intrauterine prostaglandin
    If any laceration à stitch and watch for bleeding.

    Steps for uterine atony
    Uterine massage and/or bimanual massage
    IV syntocinon or ergotamine
    Intrauterine prostaglandin if no asthma
    Internal iliac artery ligation
    Hysterectomy for life-saving

    PPH
    Primary if 500 ml until 24 hour PP
    Secondary from 24 hour PP to 6 weeks

    Most common causes of PPH
    · Uterine atony
    § Grandmulti para
    § Retained placenta
    § Prolonged labor
    § Precipitating labor
    · Laceration
    · Coagulopathy

    Michael a 25 yr old man presents with deep laceration at the wrist. The wrist is covered with a bandage. You are not allowed to take it off.
    Task: Examine the wrist
    Mention your findings to the examiner

    I’m going to examine your hand, is that alright with you? Do you feel pain now? If you feel pain at anytime, please let me know & I’ll stop immediately.

    Please put both hands on the pillow.
    · Inspection:
    · Palpation:
    § Capillary refill < 2 seconds (after finishing, tell the examiner that capillary refill is less than 2 seconds both hands.)
    § I’m looking for ulnar deformity
    § Squeeze, spread fingers (adduct and abduct)
    § Formet’s test for ulnar nerve injury
    § Median nerve:
    · Touch the pen with thumb
    · Ring for opposition
    · Sensory: close your eyes please then do from abnormal to normal site.
    · Tendon: MP joints
    see Talley & O’ Conner book
  37. OTD

    OTD Guest

    Mr. James a 45 yr old man comes to see you requesting a blood pressure check-up.
    Task: Take a brief history
    Explain to the examiner how to measure the blood pressure
    What investigation will you order

    Questions to ask:
    Risk of HT
    Signs and symptoms of HT à headache, blurred vision
    Allergy, FH of HT, stroke
    Occupation, diet, BW, exercise
    Hx of cholesterol, DM, HT, smoking, alcohol, liver & kidney disease
    PH of any operation

    How to measure BP?
    Choose any side of the arm
    Choose correct size of the cuff
    Apply cuff 2 cm above cubital fossa
    Palpate radial and brachial pulse
    start to inflate the cuff while feeling the radial pulse, until can’t feel the pulse anymore
    Start to deflate the cuff freely, put stethoscope under the cuff, hear the sound as well as feel the pulse again.
    Check another side
    Do both lying and standing

    Investigation:
    FBE
    U&E
    LFT
    Cholesterol
    Glucose
    ECG
  38. OTD

    OTD Guest

    65 yr old lady presents with recurrent pain in her abdomen arising especially in the morning.
    Task: Take a history
    Ask the examiner about the finding
    Ix and DDx

    Questions to ask:
    Risk factors (Fat, forty, fertile, female)
    · Have you ever been diagnosed high cholesterol?
    · Any blood disease?
    · Pregnant, HRT?
    · DM
    · Gastric surgery before?
    Pain question, aggravated by fatty food?
    Fever, jaundice, N/V
    Urine color
    Previous episode
    chest pain, cough
    bowel motion, dysphagia, haemetemesis

    Findings:
    GA, V/S
    Abdomen: full examination

    Investigations:
    FBE
    Cholesterol
    LFT
    U/S à stone, dilatation, thickening of the wall?
    CXR to r/o pneumonia
    Abdominal X-ray to r/o bowel obstruction
    ECG
    ERCP if obstructive jaundice

    DDx:
    · Acute cholecystitis
    · Acute pancreatitis
    · Pneumonia RLL
    · MI
    · Pyelonephritis
    · Acute cholangitis (if fever)
    · Irritable bowel syndrome
  39. OTD

    OTD Guest

    Ms. Brown brought her 3 yr old daughter, complaining of pain in the right ear. She looked unwell. O/E Temp 38.6 °C, mildly inflamed throat, tympanic membrane is red and inflamed.
    Task: Ask the relevant questions for diagnosis
    Manage the case

    Questions to ask:
    Flu symptoms
    Allergy
    Has she had this before?

    25% is viral infection especially in the 1st 24 hour; wait to see in 24 or 48 hours, it may settle down. If she complains more pain, fever and can’t eat à bring her back.

    Treatment
    Mention options about antibiotic to give now or later and check ear drum. If give, Amoxicillin for 5 days
    Increase fluid intake
    Panadol regularly for fever and pain
    F/U in 24 hours

    Ear infection à ABO is the issue to consider
  40. samora

    samora Guest

    Thanks

    thanks a lot mate wish you good luck
  41. Dr.sahu

    Dr.sahu Guest

    THANK U

    HELLO OTD ,
    thanx for posting all the valuable cases here and all the informations , this world is a better place becoz of people like u

    thanx again bye tc
  42. Guest

    Guest Guest

    thank very muh for that great efort ,it is much well appreiated
  43. dr.sua

    dr.sua Guest

    41week pregnant, 28yr old primigravida comes to you with complete of fatigue and tiredness. Her pregnancy so far has progressed normally,antenatal tests normal,18week anomaly scan normal,no previous miscarrisges, blood group AB+.

    TASK; take further history and manage the case

    In this case, I would first like to determine the cause of fatigue and tiredness. I will ask the patient when did she start feeling tired and for how long. Does she have any other symptoms associated with it-- like bleeding elsewhere, pain? What are her daily activities? Does she have any difficulty doing her usual activities? Is the tiredness relieved by resting or doing a particular activity? Any factors aggravating her tiredness? What is her usual meal-- is she a vegetarian, does she eat properly? Does she take vitamins/ supplements? Does she have any disease such as diabetes, anemia, hypertension, etc.. How is her pregnancy-- were there any problems, does she have a regular check up? How was her previous pregnancies-- did she feel tired too? Does she smoke/ drink alcohol/ use illicit drugs? I will also ask for family history of diseases and thalassemia.

    Then I will tell her that I want to check her blood to see if there's any problem. (Basically laboratory tests will depend on the history-- but at this point, I feel FBE and serum ferritin would be appropriate).

    Since the patient is 41 weeks pregnant, I would request for CTG and AFI. If not normal, I would advise induction of labor (taking into consideration also the result of examination for her current complaint which is tiredness).

    Any corrections/ suggestions????
  44. dr.sua

    dr.sua Guest

    22yr old woman on her second pregnancy comes to you to enquire about when she should do her Booking for delivery of her baby,because she lives about 80kilomaters from the hospital.She is now 24 weeks pregnant. Talk to the woman
    (previous pregnancy/delivery no problem,hasnt had 18week anomaly scan.


    .take a full history-including,first pregnancy & delivery details;any family history of anomalies,has she been on folic acid.

    2.continue with regular midwife follow-up.appropriate diet & exercise advice.

    3.book during the current visit.

    but the best window period to do the anomaly scan is 18-20 wks right?now that she has missed it,does it still need to be done?what do you guys think?

    and sorry if this 's a basic ques,but what does booking now have to do with the distance from hospital(80km)?
  45. dr.sua

    dr.sua Guest

    In the booking visit case, i was just wondering that if the question mentions the distance from hospital (80km),does that signify that we should tell her to move near to the hospital or get admitted early??

    Apart from the anomaly scan,we should do all the antenatal visit tests,if this is her first visit to you and shes never had tests done before.
  46. dr.sua

    dr.sua Guest

    26 yr old female is going to have a hip replacement surgery in 6 weeks time. she comes to you asking if she could use her own blood for this operation.
    TASK: Explain to the patient the benefit and risk of the blood transfusion; counsel the patient about autologous blood transfusion.
    QUESTIONS asked:
    *Can the patient be allowed to have autologous transfusion?
    *What investigations need to be done for it?
    *What are the criteria for selecting qualified blood?
    *How long can the blood be stored before transfusion?
    *How much blood could be collected each time?
    *How many times can the blood be taken from her?
    *What can you give instead of blood?

    The patient is a candidate for blood transfusion because of the procedure she will undergo. Risk of blood transfusion: transfusion of mismatched blood, improper handling/ collection of blood, transfusion reactions, transmission of infectious disease, air embolism, dilutional coagulopathy and renal insufficiency. Complications associated with autologous blood donation are similar to those associated with allogeneic blood donation. These include dizziness, fainting, profuse sweating, hyperventilation, and/or low blood pressure.

    Explain to the patient that autologous blood transfusion is transfusion of own blood when needed. There are four ways to transfuse autologous blood: 1. preoperative autologous blood (POAB), 2. intraoperative autologous blood (IOAB), 3. postoperative autologous blood (PoOAB), 4. acute normovolemic hemodilution (ANH). Patient can undergo autologous donation if there is no anemia (Hgb>110 g/l, Hct:0.33), elective surgery in several weeks, blood is crossmatched, no medical condition contraindicated for autologous transfusion and storage. Patients who are predisposed to bacteremia or have active infection are not advised to have autologous blood donation. Patients with stable coronary artery disease, valvular disease, and congenital heart disease may safely undergo autologous blood donation. Blood collection should be done not later than 72 hours prior to surgery. In ANH, patient's blood is collected then a cell free solution is infused. The blood removed is then re-infused during or after surgery.

    Autologous blood is generally more expensive to collect than allogenic blood. Benefit is that it is safer than allogenic blood--transmission of infectious disease is nil, patient is assured that it is an exact match thus avioding transfusion reaction, promoted blood cell production in the bone marrow. Risks are: contamination during handling and storage, accidental transfusion of allogenic blood due to mislabeling, more expensive, blood may be transfused unnecessarily because supply exists.

    Yes, the patient can be allowed to have autologous transfusion. Blood is generally collected 4-6 weeks before procedure (ideal in this case because in hip replacement surgery the patient will lose a lot of blood). Blood can be collected every 3 days or once a week. The patient may be given iron supplements during this period or may be given recombinant erythropoietin (if you want to collect more blood because you're anticipating a loss of large amount of blood).

    Shelf life of blood is around 42 days, so patient can start donating 6 weeks prior to procedure. Each collection is around 450ml of blood/ 1 unit. Blood is generally disposed if not used after the patient is discharged. If patient's prtocedure is postponed, then blood can be frozen and stored till it will be used.

    Volume expanders like LR, NSS and blood substitutes may be given instead of blood.

    Any additions?
  47. dr.sua

    dr.sua Guest

    29 year old lady who is 6 months pregnant comes to you asking about SIDS. A neighbour of hers has lost 6 month old child due to SIDS.
    Task: Counsel the patient


    we should tell the patient that SIDS doesnt have any known identifiable causes ,but there are certain risk factors which can predispose the baby to it,and also preventive measures that parents can imploy to avoid such a catastrophe from occuring.
    RISK FACTORS:
    *prone sleeping position
    *smothered airway(bed sharing)
    *artificial feeding (possible)
    *passive smoking,before and after birth
    *hyrepthermia or excess warmth
    *extreme prematurity(<32weeks)
    *parental narcotic or cocaine abuse
    *intercurrent viral infections
    *immunusation(babys not fully vaccinated)
    *boy infants are more susceptible to SIDS than girls
    *babies in their second to third month of life are more susceptible
    *young maternal age
    PREVENTIVE MEASURES:
    avoid smoking and drug abuse while pregnant.
    After birth
    *place the baby to sleep on his back,with no pillow.
    *ensure the head is uncovered
    *breastfeeding
    *ensure baby is not exposed to cigarette smoke
    *ensure he doesnt get overheated
    *bed coverings no more than adults require
    *nothing else placed in cot ,eg,soft toys

    in the end,give her booklet to read at home about SIDS, to have regular antenatal checkups,if she feels sick at anytime during pregnany,than to come back at once for treatment.
  48. dr.sua

    dr.sua Guest

    We can tell the mother that no investigatory test can predict the likelihood of SIDs. It can happen anywhere the child is-- cots, basinettes, car seats, parents arms, etc. There is no difference also whether the child is breast-fed or bottle-fed. There are no warning signs for SIDS though sometimes the infant is off color, not feeding so well, or with symptoms of a slight cold or tummy upset. It has not been proven that medicines given to babies for colic, reflux or other health problems make it more likely a baby will die from SIDS. Another prevention tip is: don’t put your baby on a water bed or bean bag.

    Regarding the epileptic child and contraceptive case, we have to ask the mother why she wants the child to use a contraceptive. Is there a particular reason? What are her concerns. We have to ask regarding the child's seizure too (severity, frequency, type) if this is controlled, what medications are being taken, any effects of the medications being taken-- is it well tolerated, when was the follow up with a doctor regarding the seizure. I would also ask regarding the child's activities-- like schooling, recreational activities, her interest, is she dating anyone, etc. I would also probably discuss the different contraceptives available and would tell her that I would ask a senior to see her since I'm not comfortable with giving contraceptives/ make decisions regarding hysterectomy/ tubal ligation to a child especially if with no indication. I would also like to talk to the child to know more information and check her capacity to understand and make decisions regarding treatment.

    I'm not sure what that guardianship tribunal is but this is what I've found: [The Guardianship and Administration Tribunal was established under the Guardianship and Administration Act 2000, and commenced operations in July 2000. the Tribunal is a simple and inexpensive way of meeting the decision-making needs and protecting the rights of adults who are unable to make a decision and put it into effect themselves because of impaired capacity.

    The Tribunal has the authority to appoint guardians and administrators for adults with impaired decision-making capacity. The Tribunal works from the following principles:

    * most people with disabilities don’t need a legally-appointed guardian or financial manager;
    * GAAT is the last resort and should only be used when a person is incapable of making their own decisions and when all other suitable alternatives have been tried;
    * GAAT’s main concern is the welfare of the person with impaired decision-making capacity.]
  49. dr.sua

    dr.sua Guest

    mum of a 13 yr old mentally retarted girl comes to you to ask for a contraceptive for her daughter. her daughter has epilepsy and is taking 2 antiepileptic drugs, she goes to school and sleeps at home at night.

    (points in history......the girls periods havnt started yet, no one is abusing her,no other contraindication to OCP's,the mom gives her the antiepileptic medicines)
    Mother also asked if hysterectomy or tubal ligation can be done (what is Guardian tribunalship?)



    Regarding this mentally retarded and OCP case, I don't think the tribunal can decide cause the tribunal is technically for adults who are mentally retarded and not children. The mother is still the guardian in this case, but the question is -- is there an indication for contraceptive use-- we have to know this. If there's none, I don't think it's appropriate to give contraceptives to the child, so will refer her to a senior just to be sure.
  50. dr.sua

    dr.sua Guest

    41week pregnant, 28yr old primigravida comes to you with complete of fatigue and tiredness. Her pregnancy so far has progressed normally,antenatal tests normal,18week anomaly scan normal,no previous miscarrisges, blood group AB+.

    TASK; take further history and manage the case



    this case, I would first like to determine the cause of fatigue and tiredness. I will ask the patient when did she start feeling tired and for how long. Does she have any other symptoms associated with it-- like bleeding elsewhere, pain? What are her daily activities? Does she have any difficulty doing her usual activities? Is the tiredness relieved by resting or doing a particular activity? Any factors aggravating her tiredness? What is her usual meal-- is she a vegetarian, does she eat properly? Does she take vitamins/ supplements? Does she have any disease such as diabetes, anemia, hypertension, etc.. How is her pregnancy-- were there any problems, does she have a regular check up? How was her previous pregnancies-- did she feel tired too? Does she smoke/ drink alcohol/ use illicit drugs? I will also ask for family history of diseases and thalassemia.

    Then I will tell her that I want to check her blood to see if there's any problem. (Basically laboratory tests will depend on the history-- but at this point, I feel FBE and serum ferritin would be appropriate).

    Since the patient is 41 weeks pregnant, I would request for CTG and AFI. If not normal, I would advise induction of labor (taking into consideration also the result of examination for her current complaint which is tiredness).

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