O&G Long case

Tan Zi Kheng Tan Zi Kheng 1.prof jamiyah, prof lee way siah, dr.Lang (external) 2.O&G 3.coming in for IOL at 38 weeks of POG. 4. 42yo, G6P4+1, background history of DM for 2 years, on diet control only. currently, at 37 weeks of POG. unwanted and unplanned pregnancy. antenatal uneventful. started on insulin at 12 weeks POG. (As usual, DM history starting 2 years ago...until now. Luckily she is a stuff nurse, so she can tell all the results for blood glucose.) 5. PE finding: singleton pregnancy, longitudinal lie with cephalic presentation. not engaged, adequate liquor volume. estimated fetal weight 2.6kg 6. normal pregnanvy with 2 years history of DM 7. Prof J interuppted me along the way I presented. Everything was in a hurry. Never stop asking qustions...even on the way to the examine the patient. The 2 other examiners just follow at the back. What do you mean by POG? How to calculate EDD? What is the EDD for this pt? since my patient's EDD is confirmed by U/S. Why she didn't have OGTT done this time? Why you say the control is suboptimal? What is her contraception method? How you ask for complication of DM? I already answered all, but she is expecting smthg else. What is the definition of stillbirth? Why peripheral neuropathy in pregnant lady? pt complaint of numbness over the fingers, but bedside when I examine in front of examiners, she kept on saying 'Tajam tajam.."zzzz How to do GCT? How to do OGTT? how to advice pt before OGTT? normal value? How to investigate the mother? ( I said all tests,even fructosamine.haha. still duno what she wanted) How to do monitoring? bla bla bla... what is the weight gain allowed in this pt? what is the normal weight gain? What do you expect to find in U/S? I said cardiac anomalies. and also nuchal translucency in Down's. (prof lee noded at the side) she asked cardiac defects in DM or GDM? I answer GDM. but WHY? When do you want to deliver the pregnancy? PE: show me how to do peripheral neuropathy?

how you clinically estimate the week of gestation? Is the head engaged? What are the signs of complication you are looking for in this pt? How to calculate BMI? ( prof I didn't calculate hers but i know is above 25.) How you know? huh, got faster way? (Yup) Show me.. what is the urine glucose test results?

Raymond Yii Shi Liang 1. Lecturers who took u: Prof. C.K Liam (silent), Prof Mary (Caucasian- external,the main examiner) & Prof Aili (silent) 2. Specialty: Gynaecology 3. Chief complaint: Sundravalli, a 49-year-old Indian lady, para 5, presented with menorrhagia for 2 months. 4. Brief history - Menorrhagia for 2 months since Oct 2010. - flooding, blood clots of multiple size with the largest one 20 cent-sized, daily 5-6 pampers fully soaked with blood. - It was associated with severe persistent abdominal pain localized at lower abdomen extending to both right and left iliac fossa. There was also low back pain. Other associated symptoms such as abdominal distension and pressure sx (urinary freq and tenesmus) were absent. No history suggestive of PCOS. - sought treatment in HTAR and was told that US showed fibroid. 5. PE finding - Conjunctival pallor, left iliac fossa tenderness, mass in left iliac fossa (I couldn't feel it, but the examiner could feel it - what a disastrous thing happening to me!) - I also told that there were scleral jaundice and hepatomegaly. But Prof CK Liam confirmed that there was none. So, be careful of the lighting condition when u're checking for scleral jaundice. - Pelvic exam was not performed becoz the patient refused. The examiner asked me what would I look for in pelvic exam: Speculum exam: vaginal bleeding, prolapsed endocervical polyps and cervical carcinoma Bimanual vaginal exam: Size, site, consistency, tenderness and mobility of uterine fibroid. 6. Diagnosis - The examiner never asked me about this. Because the history itself had already revealed the diagnosis. - My differential diagnoses: cervical CA, PCOS, DUB, endometrial CA, adenomyosis and endocervical polyps.

7. Questions asked by lecturer - Can u plz tell how would u investigate for this lady and reason for each test? Basic investigation: FBC - anemia, microcytic hypochromic due to bleeding RP & LFT - baseline for pre-op Coagulation profile - ensure that the bleeding is not due to coagulopathy Pap smear test - for cervical CA ( The examiner then asked: ' Why would u want to repeat this again since this had been done on Feb this year?' 'How long is the interval for the next smear?' If first two consecutive results are negative, then every three years. Imaging: Transabdominal US scan - fibroid (size and site) - endometrial thickness >4mm for endometrial hyperplasia and CA Examiner asked: 'What is the endometrial thickness of a pre-menopausal woman? I dunno. 'Is endometrial thickness of >4mm common in pre-menopausal woman? I answer no, but the answer is yes. ' Is endometrial hyperplasia common in pre-menopausal woman?' I answered no. Then she asked further: 'In wat situation the endometrial hyperplasia is commonly seen in pre-menopausal woman?' PCOS. Biopsy: Endometrial sampling by hysteroscopy/pipelle - to assess the histology of endometrium for hyperplasia or CA. - 'In one word, describe how would u manage this patient?' Mx depends on the age, parity and desire for future childbearing. Since this lady had completed her family, hysterectomy is the option. - 'If the woman wants her uterus, what alternative would u opt for?' Myomectomy, but it's a/w risk of bleeding. - 'I don't want this answer, any other?' HIFU - High Intensity Focus Sonography. All the best to those who are going to have their long case on Tues and Wed. May all of us pass the exam! about a week ago Report

Li Keat Oon lecturer: Prof J (O&G), Prof Lee Way Seah, External Specialty: Obstetric

I got a very easy case (Pregestational DM with vaginal discharge), but I struggle remembering things to be covered in a Obstetric history, so experienced multiple thought blocks in the exam. (run back in last minute to ask for blood group, infective scan and booking) So, please look tru the clerking details before going in. Prof J conducted the exam. Her question was easy but want really specific answers... (Like many other examiners), So, please know what's important before u "vomit" ur theories. She was surpricingly nice & I heard her questions was standard in the rounds (So, juniors, pls don't skip her round as I did =p ) Chief complaint: non, only for follow up in clinic, except for a vaginal discharge investigated very long ago. History 40yo? Malay lady. G6P4+1. in 37w POG LNMP: 11. June 2010 EDD: 18 March 2011 REDD: 15 April 2011 Past Obs: 3 uneventful but post date, then followed by 1 w history of GBS infection but no PPROM & baby healthy full term. all baby ranges 2.9-3kg. No fetal abnormalities. DM diagnosed 3 years ago after miscarriage in 2009. Previously under diet control but started insulin on 12w POG Discharge thin whitish yellow, non-foul-smelling, non-pruritic, previously investigated but nothing found. PE: - SFH: 36cm. - everything else normal except for a Grade 3 ESM at LSE, non-radiating, changes with position. Questions: 1. Difference between POA & POG (I said scan but she want sthg like conception and ovulation) 2. Fetal abnormalities in 1st trimester (I answered sacral agenesis, but she wanted more) 3. Ix (I think she want us to say "serial" blood glucose and ultrasound) 4. Common infection in GDM (candidiasis like in usual DM) 5. What is HbA1c (I think she want to stress it's not important in GDM) 6. Induction, complication and medication used. 7. Why deliver at 38w (I answered lung maturation, shoulder dystocia..., but she wanted sthg else...) 8. things u tell the nurse when the baby delivered (monitor glucose, jittering, respi distress...) 9. When u wana measure the glucose, give a specific time. (I think I may had skewed up by bombarting a number, should have said I don't know) 10. she keep on stressing on Cx of polyhydramnios in GDM in few discussions, donl't really understand some of her questions, so couldn't remember, so junior pls go explore during her rounds.

Prof Lee 1. How u detect erb's palsy (asymmetric moro) 2. What u wana do if u suspect erb's (refer ortho? Prof Lee: isit?) 3. What position u will like to placed the baby if he has erb's palsy) Good luck every1...

Li Keat Oon oh ya... in PE, she asked me: clinically, do u think the abdomen correspond to the date (I said I wana do a SFH, she said no, just look!) looking at her espression, my mind was like: Shit, did I measured wrongly?... I freaked out and remained silent (as this is a life or death answer...) Then she said: the fundus reached the xiphoid process, so? Then only I releved: Haha... yayaya.... Other Questions in PE: 1. What other examination u will do in GDM 2. What's the estimated weight in this baby? (luckily my patient told me the estimated number during the last scan. 3. How to perform OGTT? (75g..blablabla...) & values in GDM

From : Suriaraj Lecturers: Prof Nor Azmi, Prof KL Goh and Prof Azad..... =) Specialty: Obstetrics PC: Anaemia in pregnancy HOPI: 36 year lady G9P7+1(miscarriage) and one neonatal death currently at 34 weeks period of amenorrhea. pregnancy unplanned but wanted. Did conformation of pregnancy at 15 weeks POA at private clinic by UPT and ultrasound scan.Given obimin tablets bcoz of anaemia history in previous pregnancies.. (All 8 pregnancy got aneamia with 4th pregnancy requring pre delivery blood transfusions) booking at ummc at 27 weeks POA.. found Hb to be 9.1.. prescribed ferrous fumarate (1 tab OD), obimin (1 tab OD) and calcium carbonate.. at 31 weeks POA second visit to UMMC found Hb to be 8.4 and thus ferrous fumarate dose increased to 2 tabs daily.

past obs hx she had history af large babies ranging from 3.8kg to 4.48kg and hx of fetal shoulder dystocia during 4th pregnancy. No GDm hx in any pregnancy.. at 30 weeks POA onwards she started developing symptoms of anemia such as SOB, reduced effort tolerance, lethargy and occasional palpitation.. PE: all normal, baby cephalic presentation in longitudinal lie.. Got palmar crease pallor and conjunctival pallor.. Questions: no question on history.. after history i was brought to the patient and Prof Azmi told me "examine this patient".. so, i started from the peripheral examinaton eliciting the palmar crease pallor and conjunctival pallor. (make sure compare your palm with patient's to show palmar pallor). Then i proceded with abdominal palpation, presented the fetal presentation, lie and the head palpable per abdomen. Prf ask me wht is the estimated weight of fetus (i said 2.5-3, he said ok), and he ask wheter clinically liquor volume adequate or not (i said adequate).. Back in the room, profAzmi ask me when will u transfuse patient.. I said if Hb less than 8. Prof KL goh ask me wht other criteria for transfusion (ans: clinical feature of severe anaemia..) Prof Azmi asked me if i see this patient first time at antenatal clinic, how would i manage this patient?? I said start from blood ix to look for cause of anaemia and the i elaborated from there.. I said i would prescribe oral iron supplements.. he ask wht is the possible cause of the anaemia in this pt?? I said patient is a grand multipara with no spacing between pregnancy, so the iron stores are depleted.. Key word is iron store depletion.. (prof KL goh wanted to hear that) He then asked me if patient comes and tell u that her friend claims that parenteral iron is better, hw would u advice patient?? - i said efficacy of both is same but side effect profile differ and compliance is better with parenteral.. he ask me if this patient is going into labour, what are the problems u anticipate?? I said main concern is the anaemia as severe anaemia during delivery can cause a cardiovascular collapse and i said that there is possibility of shoulder dystocia coz got hx of large babies.. He ask me wht else possible complication?? -i said PPH coz she is a grand multipara thus got risk of uterine atony.. he then ask me management of PPH.. He wanted to hear uterine massage initially after syntocinon infusion and hysterectomy when all else fail.. He ask me, if u see this patient after 6 weeks of delivery and delivery uneventful, wht would you advice to patient??

- i said main concern is family planning and contrception. so he ask me about the different type of contraceptive available?? -Prof Azad's only question was wht other contraceptive method( after i have said everything on the women point of view)- I said vasectomy and he said yes.. prof azmi ask about Pap smear.. "tell me about Pap smear??".. Then he ask if patient got CIN II how u want to manage.. I said LLETZ Then he ask if patient got CIN II and severe dysmenorrhea and menorrhagia due to adenomyosis wht would u do.. The ans is hysterectomy (Prf KL Goh whispered the ans to me.. =p ) P/S: Me and Fikri shared the same pt.. I m the second student.. so make sure to ask ur pt wht the lecturer ask the previous student during PE.. The patient knows and this may help.. Good luck for the rest!!! =) about a week ago Report

Chin Yun Ann MBBS(Malaya) 06/11 Final Exam Data Store Please present your long case following this format. 1. lecturers who took u Prof BK Lim, Prof Wan Ariffin, Dr KL Ng 2. specialty Obstetrics 3. chief complaint no c/c 4. brief history 30+ years old, Malay lady antiphopholipd syndrome 1 yr recurrent abortion P7G4+2 no GDM or Hpt well with no cx 5. PE finding transverse lie

no features of APS 6. diagnosis prof didn't ask 7. questions asked by lecturer How to manage patient if presented to you? What to monitor? How to deliver? Can undergo vaginal delivery? What sign in uterine rupture? How to induce pregnancy

Saturveithan Chandirasegaran 1. Lecturers Prof Mary Ann (external from United States-O&G) Prof Sajar (PCM) Prof Lucy Lam (Paeds) 2. specialty O&G 3. chief complaint GDM 4. brief history -34 years old Malay lady, -G5P4,at 34 weeks, -history of stillbirth(1st pregnancy) -Right oophorectomy due to teratoma -high risk of GDM -otherwise normal antenatal history and emphasize on GDM 5. PE finding -general examination,thyroid,breast was normal -SFH:34 weeks -singleton,longitudinal lie,cephalic presentation,not engaged, -adequate liquor volume & estimated birth weight-2.5kg

6. diagnosis GDM 7. questions asked by lecturer (mainly by Prof Mary) -Tell me about GDM...everything...screening up to management -her risk factors for GDM -investigations...PIH,GDM -how you will manage her from now..34 weeks until the delivery -complications of GDM...fetal and maternal -classical picture of baby of a GDM mother...management... -then,started on asking questions on DVT -Metabolic syndrome-define and elaborate -half life of bromocriptine... -Last question, 2nd stage of labour, head is out, wat u wan 2 do?? Mc Roberts manouvre....elaborate.. -Bell rings!!!! Done... :) Good luck friends :) about a week ago

Norawaida Razali 1. lecturers who took u ----prof sofiah(o&g), prof azad(surgery) & prof ct lim(paed) 2. specialty ---o&g 3. chief complaint ---none 4. brief history ----40/m/g5p4 (one of the child is IUD at 38 pog)/currently at 24 pog.previous 3 pregnancy delivered via elective lscs.no other medical illness. 5. PE finding -----normal.SFH is correspond to date.got Pfannenstiel scar. 6. diagnosis

-----normal pregnancy with previous 3 LSCS. 7. questions asked by lecturer ----why i said g5p4 instead of g5p3+1?..it is because the child is at 38 weeks already.the +1 is because of miscarrige less than 22 weeks. ----because this is normal pregnancy,they give situation if she had gdm..how to diagnose...screening test..value blood sugar..teatment ----mode of delivery for this current pregnancy ---consent before LSCS ----advice aftr deliver the current pregnancy gud luck everyone!!!

Wang Jie 1. Lecturers Prof Mary Ann (external from United Kingdom-O&G)Dublin Prof ong (Surgery) Prof Zuraini (PCM) 2. specialty O&G 3. chief complaint Postmenopausal painless per vaginal bleeding 4. brief history -67 years old Chinese lady, -P5,2 months history of abnormal pv bleed -had abdominal bloatiness with significant constitutional symptoms LOA,LOW and lethargy -The pv bleed increase in size and more frequent and with blood clot -No abnormal vaginal discharge or any foul smelling discharge no any dyspareunia as husband pass away 10 years ad -no any mets symptoms like tenesmus, bone pain, jaundice or any SOB -However, increased in BO 3 x times per day occasionally recently but no abd pain and had colonscopy done at private hospital but no abnormalities - had knee pain recently also and was agg by movement and relived by rest

assured by doc is ok just arthritis and given glucosamine -Risk factors: menarche at 22 years old, no sexual promiscuity but unsure of husband , no vaginal discharge or genital tract ix b4, didnt smoke but husband do smoke at home regularly and later succumbed to it by lung ca, no OCP - Pt had done before polyp removal 10 years ago with similar presentation with bleed and dyspareunia. Biopsy normal finding B4 5 mins end clercking, pt only told me had IHD before 20 years ago and maybe angioplasty and on aspirin, antihypertensive and other CVS medication. I ad asked pt initially 5 mins got PMH ,any admission , pt said no...really SWEAT! - menopause 10 years ago and not taken any HRT and no symptoms at all -not on any supplement of vitamin or calcium only normal diet and regular brsik walking at house compound -had 5 children all breasfed and husband died now lives in Ansun with her youngest child -regular menstrual history and had regular pap smear every 1 to 2 year. (Have to ask Last Pap Smear and the result! as examiner marked down this point i noticed) -otherwise screen through MDD and any good social support from family -got guilty, sadness but no suicidal ideation...no MDD but only depressed a bit..and now ok as good support from the children otherwise just present as usual 5. PE finding -general examination,temporalis wasting but normal BMI 23.1l -abdomen no distension, no scar, no dilated vein, no obvious mass seen, many red papule Campbell de Morgan i think in elderly,examiner said ya -Suprapubic mass 3x7 cm, hard,dull percussion, can get below and can get above, globular shape,no bruit -Inguinal bilateral lymphadenopathy and liver 3 cm, no jaundice -Pain had pain in the left hypochondrium ,umbilicus and left flank and very very vague mass around. i did present but luckily examiner din ask further..no ascites. very high suspicious of peritoneal mets as pt got tell me in history there was fluid accumulation in the abdomen b4 that.. -be gentle and good to pt at least it will please the examiner and also ask any pain b4 u do or b4 examiner ask you do again, tell examiner very painful and they wont let u cont..haha

6. diagnosis Stage 2 cervical Carcinoma (told by pt in Mandarin, please know the chinese terminology for dx if you think mandarin) 7. questions asked by lecturer (mainly by Prof Mary) -Tell me risk factors for this pt and also what will be the causes u have to rule out..talk about the postmenopausal bleed. -Investigation u do in the clinics: she wants speculum in which i managed to answer at last,.i said i thought that is under examination..then the other inv? she wants ultrasound of cervix tv, sweat

-other ix? do usual blood FBC, LFT, RFT and also CT scan to stage -wat is the unusual thing in this pt? i said is risk factors not many in this pt?yup -others? a..u know how many percent of the smear negative pt had cervical cancer? i said quite high from my study..but i dunno the figure..around 20%? nope is 67% !! so precise...lolx -Wat is the staging of the cervical cancer? tell me? tell until stage 2 she was ok ad - U tell about cone biopsy..tell me about it.do when there was no spread of cancer and early focal lesion//she said for premalignant lesion.. -how you will manage her? aa...from pcm view, as prof zurainini there, i said all the explain educate, counsel and asurrance..haha she doesnt want it obviously -So for stage 2a pt, i would do Whertheim...she said no! in UK limted only to stage 1 pt..what is whertheim? and tell little about it..how do u think pt had whertheim will have? err..very bad as all the lymph nodes being removed and it will cause many problem..and she said YES! and she asnwer herself.. -So why? Err...pt had low survival chance from stage 2 as maybe there is spread -Then how u mange her? give her radiotherapy with chemotherapy..then ring ad p/s Good luck to all my fren!!! last Monday Report

Angel Kwan 1. lecturers: Prof Eugene, Prof Aisyah, Prof Wan Azman 2. specialty: O&G 3. chief complaint: menorrhagia X 2months + partially controlled asthma 4. brief history: menorrhagia x 2 months (no anemic symp, no constitutional symp & no coagulopathy symp), asthma (partially controlled: nocturnal symp, activity limitation, acute reliever>3time/week, last attack 1 month ago.) 5. PE finding: abd examination (no hepatosplenomegaly, no pelvic mass also). Demonstrate how to palpate for pelvic mass. Show the margin of abdominal U/S coverage & pelvic organ situation in patient) 6. diagnosis: uterine fibroid + partially controlled asthma

7. questions asked by lecturer I. menorrhagia Q''s: a. what further P/E u want to do? (PR exam, VE & speculum for cervical mass) b. During speculum exam, what u want to do? (pap smear & endometrial sampling) c. What's the histopath result will showed? d. Definition of dysfunctional uterine bleeding. e. What other investigation want to do? (transabdominal U/S) f. what's the coverage of abdominal U/S? what U/S that show the uterus concisely? (not transvaginal U/S & not pelvic U/S. dunno what ans prof want) f. name 3 medications that can stop the bleeding in menorrhagia & how it function. II. Asthma Q's: a. GINA guideline 2006 b. complication of asthma. if PC with SOB & chest pain + reduced breath sound, what diagnosis? (pneumothorax) b. A&E setting: acute asthmatic attack, what you wanna do & medication want to give? type of respiratory failure. oxygen therapy in type 2 respi. failure c. ward setting: how you monitor the progression of pt. (RR, PR, BP, PEF, SpO2, respi exam for wheeze & accesory m. usage) d. Klinic kesihatan setting: what u want to do during follow up of pt. (compliance, inhaler technique, optimize medication, prophylaxis) e. the latest asthma medic

Ng Boon Keat 1. lecturers who took u UK external gynae (dr Anna Mary Lensden??) Prof Ong(surgery), Prof Zuraini(PCM) 2. specialty Gynae (UK external main examiner), Prof Ong only said (come in, and forever silent), Prof Zuraini(hi, and forever silent) 3. chief complaint Post menopausal pervaginal bleeding x 6 months. 4. brief history -P5 + 1(self abortion) -PV bleeding since 6 months ago, investigated in teluk intan 3 months ago, biopsy came back with

the result of cervical CA... -history same as Wang Jie... except: -10-14 years of IHD with 2 PCI done, 10 years and 7 years ago. -Hpt 10-14 years. -partial compliance on ACS treatment -last f/u in IJN 3 months ago -husband died only 3-4 years ago wo... she said. -only risk factor for cervical CA is grandmultipara. 5. PE finding -sweat!!!! find nothing :-P except high BP, anaemia, and minimal wasting(which i forced to agree) -no mass palpable... omg... -kiv got liver enlargement 6. diagnosis Cervical CA... she want my provisional to be endometrial CA first before cervical CA. 7. questions asked by lecturer History: 1. Is there HPV vaccination during the era of patient? (i answer only recent years, not more than 20 years... she laugh, hahaha only these 3-4 years they really stress on vaccination... i said ok, sorry >.<) PE: 1. Show me the sign of physical examination: striae, anaemia, and tenderness(right iliac fossa to right flank tenderness.) 2. Demonstrate how you examine liver: eh, palpable liver to 3 fingers breath??? Swt at this moment... thinking mati lah.... but she did not drill... so, haha :-) 3. still no palpable mass wo... i think it is a pubic tubercle izzit?? dun noe... need to discuss with wang jie later or go to the ward to ask the patient. Mx: 1. How would you manage?(she really want things in systematic order... so... haha, i answer everything haphazardly and she appeared not very impressed, so the final answer is history, pe(abd), VE(speculum, then only Bimanual), then pap-smear, then colpo, then ultrasound, pipile, then only biopsy (==" swt) but i manage to answer all. ) 2. Do you know about the stage of disease? (i said i am not sure) 3. Do you patient know about her stage? (i said patient not know, apparently hmmm... the patient DID know about the diagnosis... should answer: it is unreliable from the mouth of the patient, especially if she is not so educated)

4. She said stage 2, what does stage 2 means ?( with prompting, get the answer correctly. ) 5. She want definitive management.( i answer TABHSO) 6. She ask TAHBSO got chop chop cervix bo? ( matilah... i dun know...) 7. She said what do you think? ( i answer radical hysterecromy... apparently the answer is Radical hysterectomy with clearance of lymph nodes... gg) 8. What is other mode of therapy aside from surgery? (i answer radiotherapy, yessss... everybody happy :-))

9. What so bad about surgery on uterus and vagina?( i answer bladder injury and rectum injury.) 9. What is the complication of radiotherapy? i said cystitis(prof ong nodding head) 10. Since you mention about paliative... tell me how do you want to palliate the patient?? (i dun noe how to answer, and answer alot of cow shit and bull shit... so the moral lesson izzz: dun dig your own grave. The question asked really depend on what you said...) Ok, that's me :-) i guess i pass, not with flying colours, but at least i know i didnt die.

Ct Gan 1. lecturers who took u-Dr F....(O&G, external), Prof Pan (Ortho, external), Prof MTKoh (Paeds) 2. specialty-O&G 3. chief complaint-for exam purpose 4. brief history -34/M/G4P3, at 18 weeks POG, completely well throughout the pregnancy, come for exam. 1st pregnancy: gastroschisis, left leg auto-amputated, emergency LSCS. next 2 children SVD at term at UMMC.otherwise normal, no family history of anomaly. amniocentesis done during 1st pregnancy: normal. 5. PE finding-gravid uterus + centrally located pelvic mass

6. diagnosis-fibroid in pregnancy 7. questions asked by lecturer-why refer to tertiary centre for delivery of 2nd & 3rd children? (previous anomaly, previous scar) PE: do an abdominal examination discuss abt PPH (def, classification,...) if let say pt got cervical laceration, what wil b ur acute Mx? last Tuesd

Chai Pin Ang Chai Pin 1. lecturers who took u Prof Sofiah (O&G), Prof CK Liam(Med), Prof Jesse(Paed) and another observer (O&G i think) 2. specialty: GYnae 3. chief complaint: Anaemic symptoms with menorrhagia and dysmenorrhoea (from ward 10) 4. brief history 47/I/Lady, Para 2, with underlying DM and asthma, present with menorrhagia and dysmenenorrhoea a/w abdominal mass for 1 yr, got typical anaemic symptoms. previous menses was 3-4 days but since one year ago increased to 12-14 days each cycle.10-12 fully soaked pads and a/w blood clots. Dysmenorrhoea confined to lower abdomen and the back, related to menstrual cycle, affect her sleep, relieved by analgesia she was admitted twice last month due to anaemia and was transfused 5-7 units of blood. current admission was scheduled for an operation. No bleeding tendencies or medication taken. 2 uneventful SVD children and no previous operation done. 5. PE finding Vital signs stable. Pallor on the nailbed and conjunctiva. no tachycardia or SOB. INspection: abdominal distended mainly at the lower abdomen, no scars, got linea nigra and stria ALBICANS (was struggling to come out tiz word after hinting by Prof)

Palpation: Tenderness. Mass is 27cm frm symphysis pubis, clinically 26 weeks of gravid uterus size. the mass is round, well margin, smooth surface, can get above it. Percussion and auscultation: din manage to present (no abnormal finding) 6. diagnosis: uterine fibroid 7. questions asked by lecturer a. in the room: so wat other medical problems that may cause bleeding in this patient? (bleeding tendencies, hypothyroidism), any medication that can cause bleeding? (anticoagulants.... i cant answer it even the Q was easy) b. Bedside: presence of pallor clinically, so estimated Hb in this patient? c. how to differentiate uterine mass and ovarian mass? (i ans uterine mass centrally located, can get above and prof ask: can get below it or not? i said yes... haiz...) then they ask me to check on patient again, did stupid at that time..Prof Jesse come and guide me to palpate correctly...=.=lll. The answer shd be cant get below in uterine mass, because it connect to cervix.... d. investigations: FBC (Hb low...) Prof Liam: so wat type of anaemia in tis patient? (guess wrong again, everyone is shock again..) should be microcystic hypochromic anemia because tis is chronic blood loss for 1 year. e. next: wat is your expectation of the platelet count? (i dono...) f. other investigations? they wan straight to the point of diagnostic Ix--> ultrasound, endometrial sampling g. differential diagnosis: uterine fibroid.... (i said TRO CA in the beginning..they don wan tat answer...haiz) h. DEFINITIVE management: hysterectomy last Tuesday Report

Gan Kar Wei 1. lecturers who took u Prof Mary (external), Prof Raman, Prof Khoo 2. specialty Obs 3. chief complaint No 4. brief history 31 y/o G4P2+1, 36 wk+3 days of gestation, 2 previous LSCS K/c/o pregestational diabetes mellitus and currently on insulin treatment admitted into UMMC last week dt poor controlled diabetes No other maternal and fetus complications

5. PE finding singleton pregnancy, longitudinal lie, cephalic presentation.... when i said estimated birth weight, they laughed.. i said probability of macrosomia prof asked hw to assess fetal well being if couldnt appreciate heart sound by using peanut ( ask mother about fetal movement and laptone ) she also asked whether amniotic fluid is high? ( No, fetal part is easily palpable) 7. questions asked by lecturer Hw to monitor this pt? what do u want to look for in ultrasound? 1 more question related to CTG but forgot liao complications a/w LSCS in mother and fetus.. mother- i said poor wound healing, anaesthesia...... she led me to DVT... then hw to prevent DVT fetus- i said TTN then she wanted RDS... what is RDS? Hw LSCS cause RDS? hw to prevent RDS in this pt? prof said why dont delliver at 39 weeks to decrease the risk of RDS wo.. post partum management of this patient... good luck everyone.. last Tuesday Report

Lim Chin Hwan 1. lecturers prof Chee (Medicine), prof Mary (external), prof Boey (Paeds) 2. Gyne 3. Chief complaint came for exam 4. History 49/I/F, divorcee, c/o menorrhagia and dysmenorrhea for 8 years. Details of menorrhagia and dysmenorhea, pressure symptoms, back pain, diagnosed uterine fibroid 5 years back, last yr Pap smear abnormal, arrange for TAHBSO next month. Interesting sexual history and psychiatric history. *promiscuity, more than 10 partners, few episodes of PID, 1 surgery for vulva abscess, deep dyspareunia, PCB etc. *depressed, stop working, hopeless, prev break down, suicidal attempt after divorce then live a messy life, promiscuity then..spend a lot of time exploring each symptoms and PSY history coz i was afraid got PSY lecture, pt like really fullfill somatization, lots of problems, u name it, she got it...haha...PMHx alot also, migraine, HPT, gastritis, multiple

admissions also in the past either gyne or medical prob...lot of it din manage to present oso...SHx very interesting oso, but good to explore, examiner like to hear oso...she go pee2 for 10min, OMG, next time dun let ur pt go pee2 after taking history...haha... 5. PE report vitals, BP high, not tachyc bt tachypnea (pt was anxious as I m a guy, she initially refuse to let me clerk, haha..) she was really in pain, not letting me to touch her tummy, even when auscultate lung and heart she oso c/o pain.. but i manage to get tat fibroid like 20 wk size..VE pt refuse..examiner oni ask to show pallor, signs of anemia, demonstrate on abdo examination and wat else to look for in particular to my pt.. 6. diagnosis - Uterine fibroid w suspicious cervical CA, plan for TAHBSO next month. 7. questions: -let say she is 40 y/o come to ur clinic, after hx and PE, u diagnose got fibroid, wat next thing u would do? VE n bimanual -how would u differentiate btw uterine and ovarian mass? act after say PA n VE hw to differentiate, she say u cant actually, it very difficult to differentiate btw d 2.. -then how? TAS and TVS -let say she still want to conceive n dun wan TAHBSO, wat other option? HIFU, UAE, myomectomy which i say out last as i thought she say pt dun wan surgery.. -wat are the complications rate btw all these? sorry i dunno -How would u counsel her b4 TAHBSO? -wat HRT u will give? ERT -again ask TAHBSO Cx rate? oh...i geleng my head n she ans act 10% then she smile to me...ngam2 ring....then they all smile and say u may go out now.. last Tuesday Report

Felicia Lau Prof Rokiah Ismail(med), Prof HAny(paed), external (none of my examiners from o n g, good news?? or nt???) Hopefully Obs: Placenta praevia type 4 43 year old, malay lady, referred from puspawi hospital d/t placenta praevia

no active complaint previous lscs PE: SFH 37cm, correspond to date Oblique lie inverted nipple on right side Is LSCS predispose to pp?? Risk of elderly gravida How to screen for down syndrome during pregnancy?? dun wan chorionic villus sampling-invasive, blood test-alpha fetoprotein, beta hcg, estradiol ultrasound- nuchal fold thickness main on counselling- risk of operation to her. counsel in front of examiners patient dun wan op, any other alternative?? wat is the significance of inverted nipple? since when?? y u wan 2 knw?? tat all i can recall^^

Ngam Pei Ing 1. prof siti Z (onG), prof yip (surg), prof Chim? (externa-medicine), A/P Zahar (observer but keep on giving opinion by non-verbal cues) specialty: Obs (GDM with ITP) History: no current chief complaint. but with GDM after OGTT not controlled by normal diet... on insulin monitoring. patient has ITP on predisolone. PE: normal singleton pregnancy... with feature of cushingnoid. wat to check? thyroid. why? breast. why? fundus. why? wat else?.... er.... wat about BP? yes... is important esp GDM will hv PIH as well... ok... how to check? on erect position. how to check? on supine position. how to check? Diagnosis: 1. GDM 2. ITP 3. Cushingnoid sx Questions 1. why tis pt need to do OGTT 2. wat is OGTT

3. Wat u shd advice to pt 4. wat diet hx... bla bla bla... 5. any snacks in btw? 6. wat is the normal calorie in pregnant women? wat about GDM? 7. as gestation age increase? wat is the trend of calorie u would expect? 8. wat is diabetic diet? give in details... how many calories 9. cx of GDM u would worry about 10. how u mx this patient then? 11. when can she delivered? 12 why? 13 how about her ITP? wat to worry about? 14 wat is her platelet now? 15 wat to advice to ITP patient when she is going to deliver? 16 wat the min plt level for ITP pt to deliver BB? on Thursday Report