10th Batch MBBS IIUM Blog

My clinical examination was scheduled on Wednesday, so I have a back-to-back continuous exam one day after the other without a break – a break which I badly wanted to prepare for my clinical examination. But Allah knows best, Wednesday is my exam day. The morning before clinical exam, I could not take any food despite feeling very hungry for not eating even from the day before. I could not tolerate even a sip of water. Wretching is common in any clinical exam, therefore consuming any amount of food or drink carries a high risk of regurgitation or worse off, vomiting.

So I went to the exam with an empty stomach, a tachycardic heart, a laboured ventilation, and a mounting tawakkal only to Allah. I called my parents to ask for their prayers as well.

In the quarantine room before my longcase, I flipped through the topic ‘Nephrotic Syndrome’ from the Paediatrics Protocol, deep down hoping that I would NOT get a Paediatric case since Paeds was the least I prepared for. So I was brought to the exam hall, with “Allahumma yassir, wa la tu’assir” repeatedly chanted. When the screen was uncovered, there laid a boy with a Cushingoid face, “Hah, a Paediatrics case!”. Again, Allah knows best. And subhanallah, it was a case of Nephrotic syndrome, which I skimmed through just before the longcase. The memories of my previous Paediatrics exam came flashing back as I recalled Prof Wahab’s advices.

This poor boy had steroid-resistant nephrotic syndrome. The questions asked were directly from the Paediatrics protocol. Alhamdulillah Allah helped me answer the questions well. I also stressed on social aspect of the patient – his deteriorating academic performance, steroid side-effects on his daily activities, declining health, family support, financial problems, effect of the illness to patient and his family, etc. I think these had managed to capture the examiner’s attention.

Among the questions asked were:

- Pathophysiology – starting from loss of negative charges, etc

- Secondary causes of nephrotic syndrome

- Complications of nephrotic syndrome

- Complications of steroids

- Difference between stunted and arrested growth

- Surgical complication (Asked by Dato’ J) – spontaneous bacterial peritonitis

- Meaning of remission, relapse, frequent relapse, steroid dependant, steroid resistance, etc

- How to manage relapse

- Histological types of nephrotic syndrome

- Side effects of cyclosporin, cyclophosphamide

- Mechanism of action of cyclosporin, cyclophosphamide

Alhamdulillah, Allah eased my long case.

Dr gave me the EDD and asked for POG… the pt’s was 35 weeks…

I was asked to examine pt generally….

Me: This is a lady in her..mid 20’s? medium built, conscious and alert. Hydrational and nutritional status fair. Not pale (no signs of anaemia sucha as angular stomatitis, atrophic glossitis)nor jaundice, no parotid, no thyroid swelling. No pedal oedema. Oh.. and the abdomen is distended…

Prof : *smiling* y do u think I bring u to this patient? What do you think I want tou to pick up?
Me: *slams my forehead* oh.. the patient has rashes found all over her face, forearms and legs *I’m so dead I thought*

Prof : remember hielmi, don’t be so caught up with the negative findings.. these rashes are obvious..
Me: Yes Prof

Prof : so describe the rashes…
Me: it is found most prominently on the face, multiple 2-5 mm, hyperpigmented, keratinized, looks healed… there are a few at the forearms and legs tho they look more healed?

Prof: what else do you want to do?
Me : I would like to check the trunk and with seeing the progression of the healing maybe can tell whether the pattern is centripetal or centri….*ak lupa dowh masa nie..prof pandang je lama plak tu*.. fugal?

Prof: good *phiuhh* what do u think is the cause?
Me: Varicella zoster?

Prof: ok, now examine the abdomen

The abdomen finding was uneventful… other than more rashes…. However halfway thru.. uterus contracts, so timing was done… prof prefers running commentary

Prof : so whats ur dx?
Me: seeing that she has contractions at 35 weeks, my dx is preterm contraction secondary to varicella zoster infection. However I need to complete my examination with VE and bishop scoring to see if she is in labour.

Prof: if I give u one chance… only one.. to ask a single question to the patient… what will it be? Do it…
Me: Puan, bila puan dapat ruam2 nie? Trimester pertama, dua, tiga?
Pt: baru je 2 minggu…

Prof: Ok, y that question?
Me: due to the complication it carries based on trimester.

Prof: elaborate..
Me: 1st trimester carries risk of teratogenicity…

Prof: but this pt got it at third so?
Me: hmmm.. the baby will be a carrier?

Prof: no… what do we worry bout? 10 days post delivery?
Me: fulminant manifestation of the dx on the baby..

Prof: elaborate..
Me: hmm… skin eruptions?

Prof: ok… skin infections.. anymore?
Me: lung infections?

Prof: ok pneumonia… one more we worry bout…
Me: *masa nie cuak.. mula pikir all the organs dalam badan…* brain?

Prof : so.. what brain? Be specific..
Me: hmm.. meningitis?

Prof: that is just the covering…
Me: owh encephalitis..

Prof: Yes… now one more chance to ask a question to patient..
Me: Puan ada makan ubat? Ubat apa? Tau nama ubat?
Pt: ada, antiviral tp tak tau nama apa.

Prof: but u know I believe… what is it?
Me: Acyclovir

Prof: how do u prescribe acyclovir for her?
Me: I’m sorry prof, I do not know.

Prof : ask the patient now, u will remember forever…
I start asking the pt and was told its 800mg 5 times a day for 5 days.. ak tak cek lagi…

Prof: will the treatment cure her?
Me: not entirely, the virus will remain dormant in the nerves ganglion and will resurface if the patient will undergo stress or immunesurpressed..

Prof: so whats the long term complication for this patient?
Me: it could resurface during next pregnancy and causes 1st trimester infxn and for the patient.. shingles..

Prof: what is shingles?
Me: the virus causes rashes along the dermatomal region it resides while remain dormant. Painful pustules.

Prof: which shingles are we afraid of?
Me: lumbar?

Prof: why? Its just the abdomen..
Me: owh, trigeminal nerve shingles… ocular complication leading to blindness?

Prof: yes… How do you think the patient get the disease?
Me: through contact with someone with the disease..

Prof: ask the patient…*basically one of her kids got it first*… what do u mean contact
Me: fomites? Touch? Clothes? Its not airborne..

Prof: what?*mata terbeliak* Are u sure its not?
Me: *ak degil ckp tak gak.. sebenarnya ya* hmm.. the virus resides in the pustules and contact with it causes spread of infxn..

Prof: hmmm… ok.. have u ever been infected?
Me: yes..

Prof: when?
Me: when I was 7

Prof: will u get infected now by her?
Me: no because one, I’m immune and secondly she is beyond her infectivity period because it has been 14 days..

Prof: so explain y she have it only now?
Me: she has never been exposed, this is her first infxn and also because she did not take the vaccination which at her time wasn’t in the immunization programme.

Prof:*asking the pt* pertama kali ked pt demam campak?
Pt: a’ah.. nie kali pertama..

Prof: you can go now
Me: thank you

Prof sgt2 baik.. tolong je… masa bincang ak atas kerusi while dia duduk atas katil..

CC

A 38 y.o, Malay lady, from Felda Panching, G5 P1+3, a k/c/o PCOS with 14 yrs hx of subfertility, recurrent abortions dx with anti-phospholipid syndrome(APS) and valvular heart dx with LNMP 15/6/10 SOD, no contraception but irregular menses with benefit of early scan 10/52 confirm her EDD at 22/3/11 making current px at 37/52 presents 3 days ago for 3 days history of reduced fetal movement.

Dr: so in conclusion u have a very complicated case *smiles*
Me: Yes..huhu... but i will try my best Dr

HOPI

This is a very precious pregnancy.
Suspected when missed period, UPT done positive.
1st trimester symptoms = only breast engorgement.
No episodes of PV bleeding or abd pain during 1st trimester

Booking at 8/52 POA
-Obese = BMI 35
-normotensive, blood group cant remember, rheses +ve
-blood test = nonanaemic, VDRL, HIV. Hep B non-reactive
-urine = no glycosuria or proteinuria

Due to her dx of APS, given aspirin 75mg from 10/52-37/52. Self-administered s/c clexane given from 28/52.
Due to heart dx, visit MOPD and was told can cont with pregnancy and does not need combine care.
Due to obesity, MOGTT indicated, done 3 times @ 15, 24, 34 weeks.. all normal.

So far 13 followups(biweekly) at HTAA due to her probs, all uneventful.
Scans done on every visit – singleton, healthy, no congenital abnormality, normal growth, AFI good, placentation normal with no obvious calcification.

Quickening felt at 16/52. ATT completed.
Started on FKC at 34/52.
3 days ago, reduced fetal movement(do not complete 10 in 12 hrs), did not seek medical attention because of an upcoming followup. On followup, fetal movement returned normal but warded just to make sure.

Currently no sign and symptoms of labour, no PV bleeding, FM good.

On further questioning, denied rashes of face or anywhere else, no joint pain, no easy bleeding, no jaundice, no SOB, no calf tenderness.

Past Gyn + Obs (I decided to just combine the both to have smoother chronological flow)

Attained menarche at 12, regular till age 21 when turned irregular (every 1-3 months around 3-5 days) nor dysmenorrhea.

Was married for 14 yrs however conceived first child after 6 years of trying in which she got help of two cycles of clomiphine citrate (without any complication of OHSS) and an ovarian drilling. Dx with PCOS, other than the subfertility and irregular menses does have hirsutism(moustache), was on metformin.

Her first child was born full term 9 yrs ago with weight of 2.3 kg via elective LSCS due to oligohydramnios. On further questioning, no cause was found, she denied LL, GDM, PIH or congenital abnormality. No other cx antenat,intra,post-partum. Breast fed for only a week due to migraine.

Subsequently 3 miscarriage (2006(required D+C), 2008, 2009), investigated, dx with APS.
None of the pregnancy after the first was helped with induction.
Last papsmear 3 yrs ago – normal

Medical/surgical Hx
No significant hx

Family Hx
3/8 siblings. Both parents alive and healthy. Two other sisters have similar problems of subfertility.

No other significant drug hx. No allergy

Social Hx
Housewife, SPM holder. Live with hsband and daughter. Husband mechanic making RM1500.No high risk behavior.

PE

VS BP = 130/75 mmHg, PR=80bpm, RR=18bpm, T= 36.7oC
BMI= 42
Not pale, not jaundice, hydrational fair, No pedal oedema
Respi, thyroid normal.. denied breast examination
Heart = systolic murmur of the mitral region, radiating to the axilla, grade 3… no raised JVP.

Abd : distended due to gravid uterus. Pfannenstiel scar 20 cm, no scar tenderness, SFH 37cm, singleton, longitudinal lie, fetal back on maternal right, cephalic presentation , 4/5th palpable, adequate liquor with EFW of 2.8-3.0 kg. Can’t hear fetal heart due to thick abd.

Would like to complete with VE and bishop scoring…



Discussions

List the patients problems…

What is your concern now ?
Fetal wellbeing

How do you check for fetal well-being now?
Hx-FKC, PE-serial SFH(not relevant in this case), Ix- US and CTG.

Tell me bout FKC…

Tell me bout CTG and inteprete the pt's CTG….

What is APS? korang baca la ye sendiri pasal APS

How does it cause recurrent abortions?

What is done to this patient to maintain the px? How does it help?
Aspirin n clexane..bla2 ets

How wud u manage this patient?
-Seeing that the FM carry on till 38 weeks

Y c-sec? – very precious, dun wanna take the risk of vaginal delivery.

What risk? – untried scar, risk of rupture, no previous SVD before, so there is probability of CPD… again I stress it’s a precious pregnancy.

But is she contraindicated for SVD? No

How wud u monitor if pt keen on SVD?... S+Sx of impending rupture, prolonged active/2nd stage…

How wud you prepare this patient for C-sec: Ix : FBC, GXM, PT/APTT….Make sure anaes team comes… fasting… stop clexane on the morning of surgery.. bla2 ak goreng lagi ;P

What is the cx of the c-sec? anaes[mendelson(px)? Diff intubation(obese+px)? Difficult epidural(obese)], Hge, injury to other organs, bla2 etc….

After delivery, does she still need the anticoagulant? Yes, eventhough if the delivery is successful, she is still at risk of thromboembolism due to her obesity and APS…

So when do u wanna start? 6 hrs post-surgery..bolus 5000u and maintenance 1500u

What if tomorrow she complains of reduced FM? Put on cont CTG and if there is any sign of fetal distress EmLSCS..

thank you, u can go now

Theory paper

Hari ini, seperti hari-hari lain dalam hidupku, Allah mengirimkan sebuah mutiara tarbiyah yang amat berharga… Setiap hari, bahkan setiap saat, Dia sentiasa menemani setiap langkah perjalananku, bersamaku dalam setiap hela nafasku, mentarbiyahku, tanpa jemu… Cuma bezanya, kadang-kadang aku terperasan tarbiyahNya, namun kebiasaannya, aku lalai dari petunjukNya.

Exam longcase Paeds ku tak berjalan dengan begitu baik. Walaupun dapat case simple (nephrotic), namun sebab dah tertau Dx, aku jadi bias dan terlupa nak rule out other causes of neck swelling which the patient presented with. Neck swelling tu sebab relapse of nephrotic, the fluid accumulated below his mandible, which is an unusual site for 3^rd space loss. Actually, 1^st impression when I saw the patient, dalam hati “Eh lymphoma ke ni”. Tapi once dah tau Dx, terus terlupa langsung pasal all my differentials including lymphoma & thyroid swelling. Dengan kehendak Allah, Dia telah membuatku lupa, so dalam HOPI tak rule out lymphoma & thyroid symptoms langsung.

Hari ini barulah aku mengerti apa bahayanya dah tau Dx patient. Apa akibat yang boleh terjadi kalau dah bias dengan Dx patient. Kerana kesilapanku sendiri, akhirnya aku hanya sekadar present history, prof dah suruh berhenti. Dia cakap, “Kalau you present macam ni pro nanti, you memang tak boleh pas… repeatlah 6 bulan”

“PE dan Ix tak payah present. Prof dah tau, you dah skewed to the Dx. Dah, go for your short case. Because we have nothing to discuss here”

Tak pernah exam longcase, aku hanya present setakat history. Aku bangun dan pergi meninggalkan prof dengan terpinga-pinga, membawa hati yang sarat dengan penyesalan… Kalaulah diberi peluang kedua…

Dengan kuasaNya, apa-apa pun boleh berlaku pada sesiapa pun yang Dia kehendaki… Kadang-kadang, bukan kita tak tahu, tapi kita terlupa. Kadang-kadang kita dah ingat nak tanya, tapi tengah-tengah clerk kita terpesong lalu terlupa. Kadang-kadang, kita dah prepare lain, tapi yang terkeluar benda lain. Kerdilnya kita, berbanding rencanaNya.

Sampai malam ini, masih terngiang-ngiang kata-kata prof, “Kalau you present macam ni pro nanti, you memang tak boleh pas…”

Tiba-tiba aku terfikirkan sesuatu…. Cuba bayangkan… Kalau depan Allah di Padang Mahsyar kelak.. setelah diperhitungkan satu per satu pahala dan dosa kita.. maka Allah mengambil keputusan…

“Kalau macam ni amalan kamu di dunia, kamu tak boleh pas, tak boleh masuk syurga…”

Cuba bayangkan andai ia benar-benar berlaku, di depan Allah Penguasa Hari Perhitungan… Dan kita tahu, andai tidak ke syurga, tiada pilihan lain melainkan ke…….

Lalu ketika itu, melututlah kita di depan Allah… menangis, merintih dan merayu…

Ya Allah, kembalikanlah aku ke dunia… Ya Allah, aku janji aku akan buat yang lebih baik… Ya Allah, akan kutaati segala perintahMu, dan jauhi segala laranganMu… Ya Allah, berikanlah aku peluang kedua, tolonglah ya Allah….

Tapi ketika itu, kita tahu… tidak akan ada lagi peluang kedua… ketika itu, penyesalan yang kita rasai, pastinya tak tergambar oleh akal fikiran ini… Na’uzhubillah…

Kalau di dunia, selagi nyawa belum sampai ke kerongkongan, selagi matahari belum terbit di sebelah barat, Allah sentiasa bagi peluang kedua, ketiga, keempat dan seterusnya. Kalau fail end-posting pun, ada peluang untuk perbaiki pro nanti. Kalau fail pro sekalipun, boleh repeat 6 bulan dan resit pro exam lagi sekali.

Tapi, kalau fail di akhirat nanti…?

to download...click here or

http://www.4shared.com/file/s8_qTvSu/long_case_sakai_y5b2_2010.html

thanx to shafiq and the group

good luck ^^