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Adelaide 5th of April 2008 Obstetrics and Gynaecology Case 1 25y.o. Rh-ve woman Gravida 1 Para 1, 30 wks.

of gestation came to ED complaining of vaginal bleeding and a little pain in her lower abdomen. Routine antenatal tests were normal, US at 18 wks. was normal. Task: Focused history, physical examination, management. The patient was hemodynamically stable. She developed bleeding in the morning and used 2 pads until was seen by me. The color of the blood was not bright. At the time of examination these bleeding nearly stopped and woman did not have any pain. She did not have any other complains and felt her baby kicking. Lady did not have any trauma, did not have intercourse, did not overstrain herself physically. On PE: the patient was not in distress, VS"s were normal, abdomen was not tender, fundal height was 30 cm, cephalic presentation, FHR was 140, PV- cervix was closed, spotting,uterus was not tender. Provisional diagnosis: Mild placenta abruption ( <1/6 th of the placenta has separated; blood loss is usually < 250ml= light menstrual loss to heavy menses, no clots). Management: Admission. Bed rest for the period of bleeding and for 2-3 days thereafter. US and CTG - for baby monitoring, confirmation of diagnosis. If the condition settles completely and tests of fetal well-being are satisfactory, the woman can be discharged home and will be followed carefully until delivery. Because she is Rh-ve- Anti-D gamma globulin should be administered. AMC feedback: Placental abruption ( mild ). My status: Passed.

Case 2 28 y.o. lady has past medical history of 2 miscarriages at 8 and 10 wks of

gestation. She came to your GP setting last week and you ordered some investigations. Task: Explain results of investigations and further management. Information about investigations will be provided on request. Diagnosis: Recurrent miscarrier (1 trimester). Investigations: 1 PV examination to exclude uterine myomata and cervical incompetence 2 US examination to exclude uterine malformations ( submucosal myomata, uterine septa), cervical incompetence. 3 STD and TORCH infections screening. 4 TFT to exclude poorly controlled thyroid diseases. 5 Hormonal profile to exclude PCOS. 6 Genetic consultation to exclude chromosomal abnormalities 7 Test for human leucocyte antigen ( HLA ). 8 Lupus Anticoagulation test. 9 Anticardiolipin antibody test. 10 BSL to exclude poorly controlled DM. 11 Rubella status. All tests were normal. The cause of miscarriage was unknown. Management: Monitoring in high risk clinic ( needs referral). Stop smoking. Avoid sex intercourse until 12 wks of gestation. Do not travel. Do not overstrain yourself physically. Acupuncture. Every miscarriage increases the risk of further miscarriage by 5%(20%,25%). AMC feedback: Recurrent miscarriage.

My status: Passed. Case 3 A parent requesting sterilisation of her intellectually disabled daughter. Condition 122- p 637 AMC handbook of clinical assessment. AMC feedback: Contraception request. My status: Passed. Paediatrics Case 1

You work in ED. Your next patient is a 3 y.o. girl, who has been brought in by her dad, because she complained about a painful right leg. Girl was fine last night but when she woke up this morning she complained about pains in her R. hip and difficulties to walk. Task: Focused history, physical examination, investigations, management. Girl has always been well, active. No childhood diseases, no operations, no trauma. Normal pregnancy, normal delivery, normal development, immunisations up to date. 2 weeks ago she had a flu like infection with cough, sore throat and fever but got over very quickly without any medications. On PE: The patient appeared well, not flushed, not in obvious pains. VS"s normal. Her physical examination was unremarkable except for her R. lower limb. Inspection of her R. lower limb was normal, but there was marked painful limitation of active and passive movement in her R. hip mainly on rotation and abduction. Girl had marked limp and did not want to walk. Investigations: 1 FBC , blood culture 2 US of the hip 3 X-ray of the hip X-ray was normal; US showed synovial effusion.( on request) Diagnosis: Transient synovitis/ Irritable hip. Management: Admission.

Observation. Bed rest. Analgesics. Mobilisation. The more the child can rest, the quicker the recovery ( usually settles within a few days). Patients may have a relapse if they increase their activity too quickly. AMC feedback: Transient Synovitis of Hip- Irritable Hip. My status: Passed. Case 2 You work in GP setting. Your next patient is 12 mths old girl, who has been brought in by her mother because she had been unwell with fevers for the past 48 hours. She had vomited twice, but has had no diarrhoea. Dipstick of urine ( urine bag specimen) showed protein, nitrites, leucocytes. Task: diagnosis, management.

Explanation: Your child most probably developed condition which is called UTI. A UTI is an infection in the urine. It may affect the bladder and sometimes the kidneys. UTI is quite common, particularly in young children who are still in nappies. It is usually caused by germs from the poo, which are on the skin, get into the urethra ( the tube from which urine passes out of the bladder). This can happen to any baby and is not due to poor washing or changing. Management: Hospitalization. Consultation of pediatrician. Microscopy and culture of urine specimen( supra-pubic aspiration or catheterisation). US ( to exclude urinary tract obstruction). Antibiotics: If oral medication is appropriate Trimethoprim 4 mg/kg BD or Cephalexin 15mg/kg TDS 2 If severe vomiting- Gentamicin 7,5 mg/kg IV daily and Penicillin 50 mg/kg IV 6 hourly. For 1 week! Check antibiotic sensitivity and adjust therapy in 24-48 hours. If recurrent UTI- US and MCU, prolonged antibiotico-therapy. Micturating Cysto-Urethrogram( MCU) explanation: This test involves putting catheter into the bladder through the urethra. Dye is injected through the catheter and X-ray pictures are taken. The test is done mainly to look for a condition known as urinary reflux ( VUR). Draw a picture and explain VUR.

AMC feedback: UTI. My status: Passed. Case 3 30 y.o. woman who has 2 y.o. son with Down Sd. came to your GP setting inquiring about further pregnancy. Task: Counsel the patient. Counseling: Incidence of Down Sd.- 1,4 per 1000 live births. Risk increases with maternal age. 30y.o.- 1:350; 35y.o.-1:250; 37y.o.-1:200; 40y.o.-1:100. Risk of 2-d child with Down Sd. is 1:100. Risk of Down Sd. in normal population is 1:600-700. Screening tests: 1 US for measurement of nuchal translucency bw 11-13 wks. 2 Maternal serum test for B-hCG and PAPP-A bw 10-13 wks. 3 Maternal serum ( quadruple ) test: AFP+B hCG+oestriol+inhibin A bw 14- 18 wks, can detect 85-90%. 4 CVS bw 9-12 wks ( if risk>1/200-250), can detect 100%.

5 Amniocentesis bw 15-18wks, can detect 100%, fetal loss 0,5-1%. Performance of CVS and Amniocentesis: Obstetrician will put a needle through your abdomen and womb under US to get sells of the baby from chorion or from the fluid around him/her and then analyse. By this procedure, woman can know the conclusive result whether the baby has Down Sd or not. AMC feedback: Down Sd. My status: Passed. Psychiatry. Case 1 You work in hospital. 17 y.o. girl and her family are suffering at the bedside of their mother who is in the terminal phase of liver disease. Girl was not able to speak any more after she heard her mother screaming in pain a while ago. Task: Focused history, physical examination, diagnosis, management.

History: Q- Can you answer my Q-s by indicating with your head "yes" and "no"? A- " Yes" Q- Did it happen to you before? A-"No" Q- Do you have any other complains? A-"No" Q- Have you had any infections recently? A-"no" Q- Do you feel any discomfort or any lump in your throat? A-"No" Q- Can you cough? A-"Yes", she did. Q- Any problems with your health? Are you on any medications ? Any operations before? A-"No" Q- Smoking, alcohol, recreational drugs? A-"No" On PE: GA- normal. VS"s- normal. Inspection of neck and LN- normal. Throat on examination with pocket torch and with spatula- normal (instruments were provided). Diagnosis: Conversion disorder. Explanation: There is strong link bw our brain and our body. Because you

worry about your mum very much, your body reacts to this by making you unable to speak. This condition will disappear by itself with time. Management: Consultation of Psychiatrist in hospital. Referral to psychologist for CBT. Referral for counseling. AMC feedback: Psychogenic dysphonia. My status: Passed. Case 2 You work in ED. 30 y.o. man who was previously diagnosed with schizophrenia had a relapse 2 days ago . His GP prescribed Resperidone . He took 2 tab yesterday morning, 2 tab yesterday evening and 2 tab today in the morning. After this he started to feel dizzy , drowsy and to have headache. Task: Focused history, physical examination, management.

The patient has had no nausea, vomiting, gastric discomfort, blurred vision, agitation, anxiety. But he had difficulties with sleep lust night. He does not remember what medication he took before for his condition. His health generally- OK. No smoking, no alcohol, no recreational drugs. Married, has 2 children, works as a seller. On PE: GA- looked confused P=110, RR=18, BP(lying)= 120/85, BP(sitting)= 100/70 (postural hypotension). Otherwise PE was unremarkable. Management: Hospitalisation. Stop taking Resperidone. O2. Monitoring. Chek blood drug level,ABG, BSL. Consultation of psychiatrist. Q. from examiner: What psychiatrist will do? A. Psychiatrist may decrease dose of Resperidone or may change this medication for Olanzapine or Clozapine. AMC feedback: Side effects of anti-psychotic medication. My status: Passed. Medicine and Surgery.

Case 1 25 y.o. driver came to your GP setting for some advice regarding his epilepsy. The patient was sent to you by specialist who already prescribed Carbamazepin. He had several febrile convulsions in his childhood and 1 epileptic seizure 2 wks ago. EEG confirmed diagnosis. Task: Explain condition, advice accordingly. Explanation: Epilepsy is the recurrent tendency to spontaneous, disordered electrical discharge in your brain manifestating as a seizures in your body. Draw a picture from " Patient education". You are more prone to develop this condition, because of your past medical history of febrile convulsions, then other people. Patient education: 1 Take Carbamazepin tab. regularly. 2 It is not possible to drive (seek help in Centrelink to change work ). Restrictions range for driving from 1 mths to 2 yrs, depending on the seizures.

3 Avoid swimming alone. 4 Avoid physical exhaustion, stress, lack of sleep. 5 It is better to stop consumption of alcohol, because it can interact with medicine or to cut down (patient drinks 1-2 stub of beer 3-4 days per week). 6 Regular checkups- to watch for any side effects of the medicine and to have blood test to check the level of drug in the blood. 7 Wear a special bracelet to worn about your condition. Q. from the patient: Should I take this medicine for whole my life? A.- Once complete control has been established for several years, the medication can be gradually withdrawn and stopped. AMC feedback: Epilepsy - idiopathic. My status: Passed. Case 2 26 y.o. woman came to your GP setting. She had high BP checked in 3 occasions ( 135/85; 140/90; 145/90 ). She was not overweight and did not have family history of hypertension. Task: Focused history, management. The patient started to have BP-problems 6 mths ago. She does not have any complains. Her high BP was found during regular checkup. Her health generally is OK. Woman is on OCP " Microginon-30" for 3 yrs. She did not

have any side effect of OCP before. Woman is not on any medications. The patient smokes 15 cigarettes per day and consume alcohol very rare; does not exercise, has normal diet, does not use recreational drugs. Her job is not stressful. She is in stable relationships with her partner and planning to become pregnant next 6 mths. Management: Stop OCP and use condom until ready to be pregnant. Quit smoking ( give her "QUIT KIT" and organise next appointment to discuss this problem). Life stile modifications ( exercising, reducing salt in diet ). Urine tests: Urinalysis for protein and glucose, microscopy,

urine culture. Biochemical tests: potassium, sodium, creatinine, urea, glucose, uric acid, cholesterol ( total, HDL, LDL). ECG. Renal US. Consider referral to physician. Followup in 1 week and 3 mths time. AMC feedback: Hypertension. My status: Passed. Case 3 You work in GP clinic. Your next patient is 25 y.o. man with chronic diarrhoea for more than 6 mths. Task: Focused history, physical examination, management. 2 weeks ago the patients condition got worse -he noticed some fresh blood on his stool and on the paper, no mucus, no fat. There is no abdominal pain or pain on defaecation, no nausea, no vomiting. Now he needs to go to toilet 3-4 times per day ( before- only 2 times per day), sometimes he wakes up at night time because of urge. Man lost 5-6 kg over 6 mths. He did not travel overseas, did not change his diet; his family history is unremarkable. The patient does not smoke, drinks 2-3 stub of beer per week; does not have any stress at his work place and home. He is not on any medication. There is no joints pain, no problems with eyes. On PE: The patient looks pale, no jaundice. BMI= 20. VS"s- normal. PE is unremarkable except PR- fresh blood on the gloved finger. Management: Stool microscopy and culture. Sigmocolonoscopy. Upper GIT endoscopy. Feacal fat. FBE, ESR, CRP. TFT. Total serum Ig A.

Ig A antigliadin antibodies. Endomysial antibodies. Tissue transglutaminase antibodies. Consider referral to surgeon, physician, dietician. Differential diagnosis: Inflammatory bowel diseases, haemorrhoids, fissure in ano, cancer, diverticular disease, polyps, Meckel's diverticulum,coeliac disease, chronic pancreatitis/ cystic fibrosis, hypothyroidism, irritable bowel Sd. AMC feedback: Diarrhoea ( recurrent ). My status: Passed. Case 4. 68 y.o. man came to your GP clinic, complaining of pain in his R. calf on walking , relived by rest. It is getting worse now. He smokes 15-20 cigarettes per day, drinks 2-3 stub of beer per day, has 2-3 days free of alcohol. The patient is on diuretics for his hypertension. His BMI- normal. Task: Physical examination, diagnosis, management. It was real patient. PE: GA- normal. VS"s: P=90, BP=140/ 85. After that I examined lower limbs for peripheral vascular disease: 1 Claudication on walking; 2 On inspection: no atrophic changes of skin, no color changes of calfs and feet, no ulcers, no swellings, no deformities, no visible veins, no muscle wasting, but there is absence of hairs; 3 On palpation: temperature- normal, no tenderness, capillary refill=5'', all pulses are present( femoral, popliteal, posterior tibial, dorsalis pedis ), no sensory changes, reflexes are normal (information provided by examiner ) ;4 Performance of Buerger"s test- positive ( examiner words ); 5 ABI=0,25. Provisional diagosis: Chronic lower limb ischemia . Management: Control of high BP. Stop smoking, start exercising. Check BSL, lipid- profile. FBE ( exclude polycythemia and thrombocytosis ).

Dopler US. Angiography. Referral to vascular surgeon. Aspirin 150 mg per day ( examiner said that I can"t prescribe it now). Q. from examiner: What is the differential diagnosis of calf pain? A. : DVT, Acute lower limb ischaemia, trauma, muscle pain due to diuretics, DM changes, varicose veins. (Examiner wanted to hear smth. else ). Q. from examiner: What could be the causes of patient condition? A.: Atherosclerosis, embolisation. Q. from examiner: What surgeon will do? A.: Bypass graft or enderterectomy. DO NOT FORGET TO WASH YOUR HANDS AFTER PATIENT!!! AMC feedback: Leg cramps on exercise. My status: Passed. Case 5 You work in GP clinic. Your next patient is 38 y.o. woman with chest pain and coughing who had cholecystectomy 5-6 weeks ago. You saw her yesterday and ordered CXR. On PE: pale, in distress, SOB; VS"s: T=37,7; BP = 135/85; RR-25-26; P= 94; Lung percussion and auscultation: dullness, reduced breath sounds and vocal resonance over R. lower lobe, pleural friction rub. Task: Explain results of CXR (CXR will be provided by examiner ), management. You can ask some relevant Q-s. On AP view of CXR I could see small amount of fluid on the R. side of the chest, but on the Lat. view I saw consolidation as well ( I was not sure about consolidation, so I did not tell about it, but after had regrets about this ). I explained to patient that she had a collection of fluid in the pleural space and draw a picture for her. Short history: Woman now is in pain= 7-8 ( from 0 to 10 ), Panadol does not work, cough is getting worse; she feels high temperature ; after operation she was all right, but about 1 week ago developed SOB , cough, weakness; she used to be a severe smoker 2-3 y. ago; generally her health is OK. Management: Hospitalisation. O2

Pain relive. FBE, culture; ABG. Diagnostic aspirate of effusion . Ventilation/ perfusion lung scan ( to exclude PE ). CT scan ( to exclude Ca ). ECG. Consultation of physician. Antibioticotherapy. IV fluid Q. from patient: Could it be a Ca of lungs? A.: Yes. Q. from examiner: What you can see on XR? A.: Pleural effusion on the R. side. ( consolidation ? ). Q. from examiner: What is you differential diagnosis? A.: PE, Pneumonia, Ca, pneumothorax, pericarditis. AMC feedback: Pleurisy with effusion. My status: Passed. Case 6 You work in GP clinic. Your next patient is 56 y.o. old women complaining of bloating and abdominal pain. You saw her yesterday and ordered ultrasound of abdomen (US was given with stem). US revealed 3 stones in gall bladder. Task: explain result of US, management. From description of US I explained to the patient that she had mild inflammation of gall bladder caused by gall stones. I asked if she was on any medication. She was taking Mylanta for bloating and Panadol for pain but it did not work. She did not have nausea or vomiting and any other complaints. I draw a picture of gall bladder with stones in common bile duct and explained such possible complications like billiary colic obstruction; cholangitis and added infection. Management: Refferal to surgeon Pain relieve (Panadine, Pethidine) Arranging of operation during upcoming week (explain

preoperative preparation, laparoscopic operation techniques and postoperative complications). AMC feedback: Incidental gall stones. My status: Passed. Case 7 Condition 124, p 639 AMC handbook of clinical assessment. End of life request from terminally ill patient. AMC Feedback: end of life request. My status: Passed. Case 8 Condition 137, p 675 AMC handbook of clinical assessment. Review of cytology after aspiration of breast lesion. AMC Feedback: Breast lump. My status: Passed.