End Posting of Obstetric & Gynaecology Exam
9:57:00 PM
Day 1 : The Clinical Long Case in O&G ward, 3 May 2017
I slept at 4 am last night. So tiring and I need to be at hospital by 8 am. Another 1 and half hour. *Sigh*
When I arrive at the labour room, Mdm Wee is waiting for us. Hahaha, I'm so nervous and scared. Remember Prof. Che Anuar ? the one that I told before? Hahaha, I got him as for my long case examiner. Actually, we already knew most of the cases in the hospital that time. Surprisingly the cases that we thought the least probability to come out, were the one that was chose by Dr. Poh for the long case exam. Got patient with multinodular goitre and gestational diabetes during pregnancy. Then one of my friend got monochorionic diamniotic twin with chronic hypertension ! We never had the experiences to palpate the twin. And the twin was one with the cephalic presentation and another one was with breech.
There was also a pregnant lady with asthma. Need to focus on her antenatal care and also the management outline for asthma patient in pregnancy, The pathophysiology of asthma is very important and it was taught to us so many time in our previous posting.
I'm getting nervous and more nervous. I am the second last candidate for the long case. I'm the 21 of 23 students. hahaha, I have waited from 8 am till 11.10 am for my turn to examine the patient.
What happened was, we shared patients for our long case exam. So, the patient has been examined by another student before me. The patient that time was so anxious and tired. She was in pain as she claimed she has been administered with progestin vaginally to induce labour that morning.
She refused to continue the examination, and I'm so done. Terkebil kebil aku berdiri tepi cardiac table tu tengok dia strongly refuse to continue the session. Then I tried to persuade her. She said she want to take bath. So yeaaaa, tinggallah aku kat situ sadly, alone and jotted down all important things from her pink book (Antenatal Check Up Book).
Luckily Dr. Poh ada and pujuk patient to cooperate. Thank you Dr. Poh !! I managed to finish my history taking and physical examinations. My patient was in pain so I couldn't perform any examination in front of Prof Anuar, but luckily I had examine her before that. Now I'm afraid of how he will evaluate me without physical examination. My history taking alone is not sufficient. I just hope he will consider and let me pass this time. I really hope so.
When I arrive at the labour room, Mdm Wee is waiting for us. Hahaha, I'm so nervous and scared. Remember Prof. Che Anuar ? the one that I told before? Hahaha, I got him as for my long case examiner. Actually, we already knew most of the cases in the hospital that time. Surprisingly the cases that we thought the least probability to come out, were the one that was chose by Dr. Poh for the long case exam. Got patient with multinodular goitre and gestational diabetes during pregnancy. Then one of my friend got monochorionic diamniotic twin with chronic hypertension ! We never had the experiences to palpate the twin. And the twin was one with the cephalic presentation and another one was with breech.
There was also a pregnant lady with asthma. Need to focus on her antenatal care and also the management outline for asthma patient in pregnancy, The pathophysiology of asthma is very important and it was taught to us so many time in our previous posting.
I'm getting nervous and more nervous. I am the second last candidate for the long case. I'm the 21 of 23 students. hahaha, I have waited from 8 am till 11.10 am for my turn to examine the patient.
What happened was, we shared patients for our long case exam. So, the patient has been examined by another student before me. The patient that time was so anxious and tired. She was in pain as she claimed she has been administered with progestin vaginally to induce labour that morning.
She refused to continue the examination, and I'm so done. Terkebil kebil aku berdiri tepi cardiac table tu tengok dia strongly refuse to continue the session. Then I tried to persuade her. She said she want to take bath. So yeaaaa, tinggallah aku kat situ sadly, alone and jotted down all important things from her pink book (Antenatal Check Up Book).
Luckily Dr. Poh ada and pujuk patient to cooperate. Thank you Dr. Poh !! I managed to finish my history taking and physical examinations. My patient was in pain so I couldn't perform any examination in front of Prof Anuar, but luckily I had examine her before that. Now I'm afraid of how he will evaluate me without physical examination. My history taking alone is not sufficient. I just hope he will consider and let me pass this time. I really hope so.
HISTORY TAKING
My patient is Puan X, age 35 years old, G3P2 and currently at 37 weeks of POA. Her LNMP not stated in the pink book and patient couldn't recall the exact date. Her EDD, given by the ultrasound is on 20 May 2017.
She was admitted to the ward on 29 April 2017 due to presentation of blood mixed with mucous.
Patient claimed that she notice presence of show when she was going to take bath in the morning. She noticed the show soaked half of her panty and she decide to come to hospital after that. Patient also said that there was decrease in fetal movement.
Otherwise, there was;
- no abdominal pain
- no leaking
- no fever
- no UTI symptoms
Upon admission, her os dilatation was 2 cm. She was asked to rest and monitored closely in ward. She was not in pad chart monitoring. 2 days later she noticed presence of blood spotting mixed with mucous again, soaked her panty. The doctor in charged did vaginal examination on her and the cervical dilatation that time was still 2 cm. The next day, she claimed to have abdominal pain with increase frequency and intensity. It was increasing in frequency in 10 minutes for 20-30 seconds. It then stopped for 2 minutes and then start again. The pain subsided at night. The next morning, doctor did vaginal examination again and cervical os was 3 cm dilated. According to patient, she was given drug vaginally to induce her labour because of decrease in fetal movement.
Antenatal History
She did not noticed when she missed her period. She experienced mild vomiting 2 times/day for 2 months and thought it was only one of her gastritis symptoms. She went to Klinik Kesihatan Bawah Tanjung and did urine pregnancy test and the result was positive.
Her booking date was on 9 October 2016 at Klinik Kesihatan Bawah Tanjung. Her height and weight upon booking were 157 cm and 59 kg respectively, and her BMI was 23.9 kg/m2
Series of investigations were done upon booking. Her haemoglobin level was 12.0 g/dL, her blood pressure was 110/70 mmHg and her pulse rate was 90 beats/min. The uterus was not palpable yet that time. Because of unable to obtain her LNMP, first ultrasound was done upon booking to access gestational age. It was 7 weeks and 5 days of gestation, revealed present of fetal heart.
Her blood group is O rhesus positive. VRDL and HIV screening test were non reactive.
Her latest ultrasound was on 13 February 2017 at 26 weeks of gestation revealed viable, singleton fetus with cephalic presentation. Parameters were corresponding to the gestational age.
BPD - 7.05 cm
AC - 21.58 cm
FL - 4.78 cm
She has completed her anti toxoid tetanus (ATT) immunisation, 2 doses at 20 weeks of POA on 23 April 2016. Oral Glucose Tolerance Test was done on 23 April 2017, at 36 weeks of gestation at KK Bawah Tanjung. and the result was normal. She had experience mild pregnancy symptoms such as nausea, vomiting and lethargic during her first trimester (1-12 weeks).
Gynaecological History
She attained menarche at age of 13 years old, with regular cycle of 28-30 days interval. Bleeding duration was normally 6-7 days, with peak flow on 1st and 2nd day of menses.
Otherwise,
- no dysmenorrhea
- no intermenstrual bleeding
- no post coital bleeding
Obstetric History
She was blessed with two children. Both were delivered normally via spontaneous vaginal delivery at term, ranging birth weight of 2.7-2.8 kg. Both are healthy girls. The first child was born in 2003 and the second child was born in 2010. The was 7 years of gap spacing.
Contraceptive History
Patient did not practice any contraceptive method.
Past Medical and Surgical History
Nil
Drugs History
She only take the vitamins supplement for pregnancy that was prescribed by the klinik kesihatan.
Family History
Her mother was diagnosed with heart disease. Her father has passed away in 2001 due to intestunal cancer. Other family member are healthy.
Nutritional History
She take 3 major meals per day of normal balanced diet with snacks in between.
Social History
She work as an assistant in a shop. Her husband's age is 39 years old, working as sellers. He is a smoker.
In summary, my patient is a 35 years old lady, G3P2 at 37 weeks of period of amenorrhea came due to show presentation. Patient is in labour.
I'm so done with O&G. For sure this is not my field ! What to do?
Questions that been asked to me by Prof Anuar were:
- What are the cause of decrease fetal movement? - engagement of the head to pelvis, oligohyroamnious, mass in the uterus.
- What investigations I would want to do in this patient? Hb evaluation, CTG, Ultrasound
- Why is the purpose of CTG? - to access fetal well being, to access fetal hypoxia and fetal acidosis.
- Fetal hypoxia because of somatic or neurological hypoxia? Somatic hypoxia
- Which component of CTG reflect the fetal autonomic nervous system? The baseline variability (beat to beat varies).
- Autonomic nervous system was controlled by what? Baroreceptor and chemoreceptor.
- How to diagnose fetal acidotic, what test should be done? Arterial blood gas sample from fetal scalp blood testing.
- The management? Allow labour.
Day 1 : The Written Examination in college, 4 May 2017
Well. Conclusion for today is everything is suck. The MEQ and OSCE were so hard to answer as we were prepared for the diseases in pregnancy or the abnormal labour. Instead they gave us the mechanism of normal labour. Hahahaha, I've read it but I could only remember few steps that involved in the mechanism. I'm doomed. I just hope I pass this posting. That's all. Gotta qada' my sleep now.
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