G&O practical exam (Part 1)

The theory exams of the Final MBBS ended some days ago. I'm even thru the G&O practical exam. Next is surgery. Great subject, great teachers...

About the Gynae & Obs practical exam.
The pattern was as follows... One Long case, One Short case, one table for the partogram, an Obs table, and a Gynae table.

The Gynae and Obs tables had their separate sets of instruments and specimens. The Gynae table had HSGs in addition, and at the Obs table, a Fetal head and Maternal Pelvis.

My Long case was an Rh-ve pregnancy in a primigravid woman at 38 weeks of gestation. Everything was perfectly normal, and since this was her first baby, there was especially less to ask related to her Rh negative condition. She was diagnosed to be Rh negative during routine antenatal blood grouping.
Points to note:

1. How to present to the examiner the fact that she is Rh negative:
The Rh negative blood group is usually mentioned to you by the patient. Ask her, "How did you find out?" The answer is usually "During antenatal checkup". This is exactly what you should tell the examiner. "The patient received regular antenatal checkups, IFA tabs, blah, blah. Routine blood tests during her checkups revealed an Rh negative blood group (if she can't tell you the ABO group - this happened in my case, and she didn't have her ANC card in the exam hall)".

2. How will you manage the case?
As always, start with Investigations. Investigations for Rh-ve pregnancies are given in any book (including D.C. Dutta). You might want to leave out the "ABO & Rh grouping" coz it's already been done as a part of ANC. The first thing you would want to do is an Indirect Coomb's test on the mother's blood to check if she as Anti-RhD antibodies. Further tests are fine, depending on how much your examiner wants to hear.

3. Suppose she has no evidence of sensitization. Do you give her Anti-Rh globulin?
The answer is, there is no harm, but the stuff is quite expensive. If she can afford it, then yes.

Enough for now. Gotta study for Surgery. More coming later.
N.B. ANC = Antenatal Care

This blog was supposed to help me talk about medicine, learn myself, while teaching others. I guess it's been such a hectic time at college, with so little time for everything, I haven't been able to keep up.

What have I been doing?
Well, college takes up a lot f time.
Apart from that?
Flying planes, from Airbus A320s to F/A-18s...
(on a simulator, of course)
Playing lots and lots of FarmVille on Facebook
Not studying
Going out with friends...

Well, many things, apart from studies.
So, where am I gonna get time for this? :-P

Pseudopancreatic cyst

A 50 year old female presented to the Surgery OPD with a an upper abdominal swelling for the past 18 months. Her history revealed that she had developed a dull-aching, continuous epigastric pain 18 months ago, which was not aggravated to relieved by meals. She, however, vomited a greenish fluid after every meal. The vomitus did not contain old food particles, and was not foul smelling. She also developed steatorrhoea 2 days after vomiting began. These symptoms gradually regressed, and she noticed an epigastric lump gradually developing, which increased to the present size in 6 months, and has remained static for the past 1 year. The lump is associated with slight dull-aching pain. The patient was lost her appetite, and and has continuously been losing weight for the past 18 months.
She does not report of any blood in vomitus, melaena, or jaundice. Her bladder and bowel habits are normal at present. Her appetite is diminished. She sleeps normally at night.
A past history reveals jaundice 5 years ago. There is no history of any other major illness, prolonged drug intake, or hospitalization. She is not known to have tuberculosis, diabetes or hypertension. She never took OCPs. She has no known drug allergies.
She is not addicted to alcohol, and denies any other addictions.
She has two children, born by normal vaginal delivery at home. One child was aborted 10 years ago due to trauma to the abdomen.

Her general examination reveals poor nutrition and moderate pallor, but is otherwise normal.

A local abdominal examination reveals a solitary, tense cystic lump, globular in shape, measuring 23 cm x 19 cm lying retro-peritoneally in the epigastrium, extending to the left hypochondrial, left iliac and the umbilical regions. It has a smooth surface and well defined margins, apart from the upper margin which disappears under the costal margin. It shows a positive fluid thrill. It moves slightly with respiration. It is not compressible or reducible, shows cough impulse or pulsations.
Umbilicus is shifted downwards and to the left. The abdomen shows stria gravidarum, and venous prominence in the flanks.
Deep tender points show no abnomality. Hernial orifices appear normal. PR and PV examinations were not done.

Provisional diagnosis: Pseudo-pancreatic cyst in a 50 year old female.

DIfferential diagnoses:

1. Pancreas: Cystadenoma/Cystadenocarcinoma
   
2. Hydatid cyst of pancreas
3. Spleen: Hydatid cyst
4. Liver: Hydatid cyst
5. Simple cyst of liver
6. Mesenteric cyst

Investigations to be done:
USG upper abdomen: I will expect a cystic swelling in relation to the pancreas.
Serum amylase & lipase: I will expect elevated values.
General Pre-anaesthetic checkup

Definitive treatment:
Drainage of the cyst. Most commonly, internal drainage is done, by making a communication of the cyst with the gut, i.e. stomach, duodenum or jejunum.

Complications of pseudopancreatic cyst:

1. Infection
2. Hemorrhage
3. Rupture of the Cyst
   
4. Gastric Outlet Obstruction
5. Obstructive jaundice