Dysfunctional Uterine Bleeding

Im rewriting the answers for my sessional exams. Urgh, i know it was a disaster.

Definition of DUB : It is a state of abnormal uterine bleeding w/o clinically detectable organic,systemic pathology and iatrogenic causes.

It a diagnosis done by ruling  out :

• pregnancy  related complications
• tumours of uterus -Benign (Cervical polyp, endometrial polyp, fibroids)
• Infections
• foreign body- IUD
• Systemic -Hepatic,Renal,
• Blood disorders
• idiopathic
• endocrinal disorders

Types of DUB

• Anovulatory (80%) -Threshold bleeding of puberty menorhagia,Metropathia Hemorhagica,Premenopausal DUB
• Ovulatory(20%) - Irregular ripening,Irregular shedding, IUCD insertion,following sterilization operation.

Signs and symptoms

.Abnormal bleeding are associated with  or without ovulation and are grouped into:

• Ovuular bleeding (polymenorrhea/polymenorhagia/oligomenorrhea/menorhagia of irregular shedding and ripening)
• Anovular bleeding (usually excessive bleeding due to anovulation causing endometrium growth is under unopposed action of oestrogen in absence of progesterone).

Investigations of anovulatory DUB

• Detailed history of menstruation ( no of pads used, passage of clots size & nomober, and duration of bleeding)
• History of IUCD or  steroidal contraception
• History of abnormal bleeding from gums, injury site, epistaxis.
• Bimanual (per vagina, per rectal) examination done to exclude pelvic pathology.(  PV done  for all except virgins)
• Blood haemoglobin estimation,platelet,PT,prothrombin time,
• TSH,T3,T4 estimation done is suspected thyroid cases.
• D&C ( Diagnostic uterine curretage)
• USG and colour Doppler (endometrial hyperplasia : ET> 12mm,hyperechoic,and regular outline)
• Hysteroscopy
• Laparoscopy
• Hysterography

Plan of investigations : Blood values->USG->D&C->Hysteroscopy/hysterography->laparoscopy

Management of anovulatory DUB

DUB treatment includes a general,medical and surgical treatment.

General treatment - Rest, correct anemia,

Medical treatment - Hormones,Prostaglandins synthethase inhibitors,Antifibrinolytics

Surgical treatment - Uterine curettage,endometrial ablation/resection,hysterectomy

Gynaecology terms

Menorrhagia : It is a cyclical bleeding occuring with excessive amount(80ml) or duration or both.

Polymenorrhea : It is  a cyclical menstrual bleeding that occurs less than 21 days .

Oligomenorrhea : It is a cyclical bleeding that occurs for more than 35 days.

Hypomenorrhea: It a scanty menstrual bleeding that occurs less than 2 days.

Metrorhagia:It is irregular and acyclical  uterine bleeding.

Menometrorhagia: It is irregular and excessive bleeding in which menstruation is difficult to be identified.

Surgery Practical Examination

Dear me. Please undo this mistakes. DO NOT REPEAT THEM !

Sincerely,

The idiot medic student.

I came to the department of a foreign hospital. I did not study here. Tapi, aku redha dengan apa yang akan terjadi. Sebab ini salah aku sendiri. Aku yang tak kuat untuk hadapi peperiksaan. Hari ni , aku kena hadapai semua yang kat depan mata dengan sendiri. Tak ada siapa yang akan tolong aku. Aku ibarat anak yatim. Tiada tempat nak bergantung. Tiada tempat nak mengadu. 

Malam tu, kepala agak serabut nak study yang mana satu dahulu.

Sepertimana nasihat kat sticker note aku,

" The key to success is not prioritizing your schedule, 

but rather scheduling your priorities"

Well said advice i think.

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

0700 am : Went to hospital early. 

0800 am: Start taking history of each cases.

1000am : Surgery viva session commenced.

1.30 pm: Lunch break.

200pm : Viva commenced. Ortho viva started.

500pm : Instruments surgery, specimens, X-rays for ortho, simple surgery procedures, 



Long case surgery

35 year old male, Jaya, came with swelling of the right mouth and chin  for the last ____month.
Also c/o wound and halitosis in the mouth.

GPE: 
- concious , cooperative
-well built, moderately nourished
- Pallour -ve, icterus -ve, clubbing -ve, cyanosis -ve, lymphadenopathy +ve, edema -ve.

Mouth and oral cavity examination:

Inspection and palpation:

• Nose: Normal
• Maxilla: Normal
• Mandible (jaw) - Right angle 3 multiple swelling , border diffused in nature, surface irregular,extent 7x5cm extending from right angle of the lip and lateral border of mandible,part of swelling covered by hair, firm on palpation, fixed to the bone, skin over swelling not pinchable.
• Lip: Normal
• Oral cavity: 2 ulcer wound present on the right side of buccal mucosa extending to the inferolateral border of the tongue. wound size on buccal mucosa(4x1cm). Wound on tongue (4cmx2.5cm). Both wound no discharge, covered by pus and  slough unhealthy granulation tissue,beaded(?) elevated border(?) , blood tinged discharge, no bleeding on palpation, firm on palpation, involved teeth shaky mobile upon palpation, tenderness mildly present on palpation, 
• Gingiva: swelling , oedematous, cyanosed, tobacco stained,firm on palpation, 
• Tongue: An oval wound present over lateral margin of the right side of the tongue, induration present, border elevated, covered with pus and serous discharge.
• Teeth: Poor dental hygine, carries present, mobile teeth, tobacco stained.
• Uvula: Normal, no deviation.
• Lymph node : multiple ipsilateral nodes but all less than 6cm N2B

DDx: Carcinoma of buccal Mucosa (  Viva : Squamous Cell Carcinoma) invading the right jaw and tongue. 

Stage 4: T4,N2B,M1 

Short surgery case

A 40 year old male from kerala presents with swelling behind his back.

Inspection:

• A diffuse swelling present over the ________(lumbar vertebra/back?)
• Puncta present over the swelling. 
• No discharge present.

Palpation:

• no local rise of temperature.
• no tenderness.
• Cystic in nature
• margin well defined, border not indurated,
• Skin over swelling; not pinchable
• Center : indented
• Mobility: Horizontal+ve, Vertical +ve,
• Slip sign -ve
• Fluctuation test +ve
• Translumination test: -ve

DDx: Sebaceous cyst/ Lipoma/

Rx: Surface excision.(?)


Surgery short case

A 30 year old female with neck swelling c/o hoarseness of voice since 1 month.
C/o pain radiating the shoulder, aggravated on drinking, relieved on medication.
No h/o headache, no h/o deafness.

Inspection: 

• One diffuse swelling, present over the middle of the neck.
• Size 3cmx5cm, 
• no redness or discharge.

Palpation:

• No local rise of temperature
• No tenderness
• Mobility: non mobile(fixed?)

Ddx:

 -Papillary thyroid cancer invading recurrent laryngeal nerve.(Under 45 year,female,solitary nodule,deep cx LN involved,fixed LN,) 

-Tuberculous LN

-Secondaries in neck 

Orthopaedics Short Case

A 55 year old female, Mangala from Bankart came with trauma of the right hand two month back.

HOPI: 

H/o trauma suddenly and was treated by plaster cast for 25 days. When the trauma has not been cured, she was admitted to FMH for 5 days. Plaster cast was changed for 5 days.After 1 month of care , she was sent for operation when the trauma still not cured. She c/o pain since 2 month back , and not relieved  even after treatment. H/o of decreased movement range.
c/o pain and swelling of the right wrist.


Examination of the hand

• Irregularity of the lower end of radius ( dinner fork deformity)
• Th styloid process came to lie at the same level / higher than the ulnar styloid process.
• Dorsal tilt present.
• Tenderness present

DDx: Colle's fracture complicated by Sudecks osteodystrophy(pain,swelling,stiffnessof hand after removal of plaster) 

Rx: immobilise, below elbow plaster cast for six weeks



Orthopaedics Short Case

A 65 year old male came with a  left foot drop(?) since 15 years. 

HOPI: 

H/o foot drop for 15 years, h/o leprosy  for 45 years , on medication for 5 years,
 Right leg: No sensation from middle calf to ankle, heel normal, 
Left leg: foot drop for 40 years back, decreased sensation,
Both legs have skin desquamation,No pain on both legs.
Able to walk, gait normal, left foot touching the ground.
No h/o physiotheraphy.

Examination of left leg

• Attitude: Patient sitting on the bed, both knees same level, adducted, heels touching the floor, normal dorsiflexion of the ankle, no shortening, no swelling, skin desquamation present,no tenderness, no local rise of temperature, sensation decreased, wasting of muscles present, 
• movement active: inability to dorsiflex  left ankle ,  both knee extension and flexion normal,
• Movement passive: no rigidity/spasticity on both legs. left ankle in plantar flexion upon elevation of left leg above ground.

DDx: Foot drop caused by common peroneal nerve palsy affected by leprosy.

p/s: In ortho no need to write case sheets , but they ask for the paper anyway. So, just write in the paper.

Tracheostomy

Definition : An opening made in the trachea is called tracheostomy.

Indication:

• Emergency: choking, stridor
• Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency

Contraindications:

• Anaplastic carcinomathyroid patients presenting with stridor due to infiltration of growth into trachea. 

Anaesthesia: LA

Procedure:

• Incision: Tranverse curved incision 3-4cm at the level of 2nd tracheal ring. 
• Dissection: Skin , subcutaneous tissue and deep fascia are incised.Isthmus of thyroid is separated.
• Procedure: A transversed curved cut is made at the level of 2nd tracheal ring, its edge is held by Allis forceps and a small cuff of cartilage is removed. Cricoid hook can be used to stabilise the trachea (found more usefull in children).
• A suitable sized tracheostomy is introduced within.
• The cuff of tracheostomy tube is inflated by using 2-5ml of air and is held in place by passing a tape around the neck.
• Confirm the tube in the trachea not in the subcutaneous plane.
• Confirm air entry into both lungs.

Post op Rx

• Suction of tracheostomy tube
• Regular dressing
• Humidification of air
• Check for air entry

Post op complication

• wound infection
• Air leakage
• Improper air entry
• cricoid stenosis

End Posting 9th term OBG

Erm, lambatnya update. 

Sorry, malas sungguh. Tapi, mengenangkan ini akan membantuku di kala nak dekat finals nanti, ku laratkan jugak. 

Kali ni dapat viva dengan cekgu old-school. The HOD. A very quiet male doctor. The only  old Beetle surrounded by Flowers in the OBG garden. Heheh. I wonder why they made him the Head of Department. Maybe he is guy? An d female can't take the post because they are too emotional and not as rational as the male colleagues when put under pressure? People keep saying that it is really distressing being in this specialty.

I got this  combination of worst case scenario during postings. A combination of many differential diagnosis and topics in both Gynaecology and Obstetrics. 

I think it is better to present the Obstetric case first as the questions are quite predictable.

Viva End Posting (Obstetrics)

Summary : 33 year old, G2P1L1  at 38 weeks 5 days of gestational age, with previous lower section caeserean section and overt diabetis melitus with single fetus, cephalic presentation and mobile head.

• Urine pregnancy test. Other method of confirming pregnancy.
• Folic Acid. Why it is given?
• History of fever with rash. How Rubella is manifested?
• Tetanus toxoid. Why it is given?
• History of pedal oedema(pitting type). Differential diagnosis of oedema in pregnancy.
• History of previous LSCS indicateed by Cephalo pelvic disproportion. Was started insulin after delivery. Stopped after 2 month. 
• What is Lower section caesearean section? Describe the incision made. 
• Past history of Diabetes melitus since 1 year.On Medication.
• On Examination: thyroid enlarged
• Inspection: overdistended abdomen, globular shape. Falnks full.Horizontal scar present 3cm above symphysis pubis measuring 13cm wide. No keloid, non tender scar.
• Palpation:

            Fundal grip: Soft irregular, broad mass suggestive of breach.

            Lateral grip: Right- Continuos uniform resistance with smooth hard surface                                             suggestive of spine.

                                 Left: Small irregular Knob like structures, suggestive of limb                                          buds.

          1st Pelvic grip: Ballotable mass, non enggaged.

          2nd pelvic grip : Fingers converged, not enggaged.

• Auscultation: Fetal  heart sound not heard. Why?

Viva End Posting(Gynaecology)

Summary: 53 year old(menopause) P3L3 with chronic cervicitis/vaginitis/endometrial polyp/adenomyosis/malignancy of cervix/endometrium

Chief complaints : History of passage of white discharge x 3 month

                              History of backache and abdominal pain x 1 month

                              H/o bleeding per vagina x 1 month 

• DDx of discharge per vagina. Colour? 
• What is clue cells?
• DDx of painful lower abdomen.
• DDx of mass in the lower abdomen.
• DDx of bleeding per vagina in menopausal woman.
• What is PID? Definition.

Lesson learnt: 

-Bring ALL books related. Even the note books. 

-Fight and dont give till the end. Open your mouth and speak clearly and loudly These people are getting old. Make their job easier. Dont say a word if you dont know anything. Just shake your head and ZIP your mouth.

End posting 8th term Medicine Unit 5

Alhamdulillah.
Segala puji bagi Allah yang memegang hati dan takdir manusia. Sesungguhnya, pencapaian dan pujian hari ini bukanlah milik mutlak bagi diri. Tetapi, milik Tuhan yang meminjamkan kekuatan untuk belajar.Yang menjadikan ujian itu setimpal dengan keupayaan diri. Saya mampu sebenarnya.

Tapi, hakikat manusia itu lemah dan tidak sempurna. Sesempurna manapun persiapan diri, masih ada kesilapan dan khilaf yang berlaku. Ye, saya juga manusia biasa. Buat silap dan tidaklah mahu berbangga dengan kesilapan itu... InsyaAllah, akan aku baiki diri dan tidak mengulangi kesalahan itu. Ya Allah, jauhkanlah aku daripada menzalimi diri sendiri dan pesakit-pesakitku kelak.

Jika aku jatuh dan berlemah hati, berilah aku kekuatan untuk kembali padaMu. Jadikan aku hamba yang bergantung harap sepenuhnya padaMu. Jadikan aku hamba yang bersangka baik dengan janjiMu.

Segala pujian di langit dan di bumi hanya padaMu.

Alhamdulillah.


Do not repeat this mistske.
B/p values never in odd number! Only 2mm calibration.
Dont forget history n sign of meningeal irritation.
Dont forget to write impression at the end of your case sheet.

p/s: Dr. S of unit 5 medicine said, "Good" at the end of case presentation.

Today is my first ever CNS examination.

Summary: Middle aged male pt came with h/o left sided weakness 5days back with history of inability to sit up from bed, drowsiness and past history of hypertension, smoking and alcohol consumption.

Impression: Cerebral thromboembolic stroke of left hemiplegia with lesion at level of internal capsule suggested by generalised motor deficit with sparing of facial nerve palsy.
 

2nd sessional Final Year Mbbs

I have to stay strong.

I have to.

InsyaAllah...

Oh, you should.

Because,

Life is short.

Aim high dear,

Aim to shoot the moon,

At least,

When you fall,

You'll land among the stars...

Surgery Note

Hernia 

• Herniotomy 
• Herniorhaphy-approximate the inferior border inguinal ligament 
• Hernioplasty 
• Incisional hernia  
• Children inguinal hernia-rx:herniotomy, coz no post wall 
• Must know-anatomy of inguinal ligament. 
• Pure tissue repair 
• Mesh,sutures used 

Varicose vein  

• Tests 
• Hemorrhage  
• Complications  
• Investigation 
• Treatments 

Carcinoma of stomach 

• 
  

Appendicitis 

• Left iliac fossa pain radiating to right aggravated on hip flexion n adduction 

Gall Bladder palpable  

• Troisiers law, in jundiced pt, any palpable gallbladder is not due to stones. 

Jaundice  

• Obstructive jaundice 
• Achylorius jaundice 
• Typhoid Mary : enteric fever 
• Back pressure 
• Surgical jaundice 
• Congenital hyperbilirubinemia 
• Splenectomy 
• ERCP 
• Charcot's Law:  
•  itching 
• Parts of CHD : supra,retro.inferior,intra 

Umbilical hernia 

• Infant: no surgery,self limiting 
• Linea alba,  
• Vertical vs transverse incision  
• Induce hernia, child n adult. Cough n cry baby 

Colon 

• Choletectomy 
• Choletotomy 
• Valvulos colon 
• Haustra 
• Sigmoid colon,maize 
• Congenital mega colon 
• Hiershsprung disease,ganglia... 

Epigastric Hernia 

• Many multiple defect 
• Weakness over the fascia 
• Linea alba is further defect 
• Mesh sutured around,the defect 
• Below or above the umbilicus 
• Paraumbilical vs umbilical hernia 

End posting 9th term Paediatrics

Arghhh...

This time i didn't do well. I was told to read more. This is not enough. Yeah, i didn't come prepared. Not 100% prepared.

I left my notes and books at home.I shouldn't do that next time.
Geram geram geram....
Geram sebab kes ni dah banyak kali aku present. Pastu, still tak confident nak jawab apa cikgu tanya.

I've repeated my answer soo many times and yet she didn't understand. Maybe i spoke too soft? Too slow?Mumbled? My accent? Okey, i admit it was my fault... *sigh*

My patient this time is super cooperative and playfull but i screw things up. I knew it was my fault...

There is no next time. Because next time it would be real. I hope i will be better next time.

Viva Questions

• What is nephrotic syndrome? Give proper definition.
• What is remission? What is relapse?
• Treatment for first time episode of nephrotic syndrome.
• Rx for relapse?
• Rx for remission
• Rx for steroid dependance?
• Method of assessing organomegaly in presence of ascites.
• Child draw a stick man. Give the age of the child.
• Development - motor,fine,social,personal of 7 year old.

Actually i realised that this kid had supraclavicular pulsations and elevated JVP of which i didn't say because it is too risky and way beyond my expertise. So, i stated only the OBVIOUS and most common findings in nephrotic syndrome.

He has fast breathing >30cycles/min, tense, distended abdomen, positive fluid thrill, positive shifting dullness. Just not confident enough to mention that the kid had signs of hydrothorax. No hydrocoele. There is puffiness of the eyes, abdomen distention and pedal edema of pitting type. No organomegaly. No hematuria. No fever. No artralgia. Nails have white bands, pale palm. He had history of hypertension and maybe that's why he had elevated JVP.(well it looks like it)...(-__-)" im not sure....

Next time, be sure.Be confident. You will get this right next time.

Aminn.

 

Rambles...

What is the point of attending posting if there is no one teaching us something?

Now, i finally get it.

Even though there are no people like Malaysian teachers who spoon feed us to succeed in big big examinations like PMR and SPM.Here, we have to totally depend on ourselves.

Depend on our own interest and passion towards medicine. Depend on our ability to make friends and gain help from them in times of need as they were our only support system.

They wont care about you coming to class or not or is passing in exam's. They have patients to worry about. All they care is your attention for them during their classes.

The point of such system is that they require us to be INDEPENDENT and strive for our own DREAMS PASSION.

I may have been too comfortable in tuition and mentor mentee system that i failed many of my exams at the lack of such system here and was aggravated by unpolished independent learning skills.

Or maybe, it was just about the lack of my own will to SUCCEED has faded over the time. Degraded and demotivated by the so unsupportive education system, lack of inspiring teachers, lack of little notes and motivation camps that we used to have everytime the exams is around the corner, really rude or lack of discipline everywhere with no one to catch or give punishment to students. If there is any teachers willing to care, they have remind those students countless of times of their behavior. I was studying for the sake of my own guilt. Guilty for a lot of things. I didn't study for the sake of LOVE of KNOWLEDGE.

Why is it so difficult to LOVE something ?

What happened to the girl who loved to study for her own sake ?

Posting or classes are more important than studying alone in the cozy room and in the end falling asleep and not remembering what has been read. I too, faced the same dilemma.

Class or self study? Which one is better?

I learned it the hard way that what ever happens,or how bad the class was or the teaching was, class and posting during day times is precious and can never be replaced by notes we made by reading books.

Reading and going to classes is like going to charted ocean. Not reading and going to postings is like sailing an uncharted water. Not reading and not going to class is like not going to the sea at all!

Knowledge makes us prepared of what is happening,but experience makes us CONFIDENT in upcoming situations. Be it a predictable ones or the unpredictable ones.

So, attend your classes and posting no matter how boring it is. Because you will never know what will you NEED from classes that has been lost...