Um

1.
34yr old gentleman presented with on and off SOB triggered by cold
weather. He is also a smoker, 20 pack yrs. Chest physician requested
for spirometry, please counsel him.
Suggested marking scheme:
Introduction and orientation
Check patient understanding regarding his/her condition
Check patient understanding regarding lung function test
Explain to the patient about:
1. Lung function tests
A spirometer is a device used to measure timed expired and inspired volumes, and from
these we can calculate how effectively and how quickly the lungs can be emptied and filled.
The results are normally presented as a graphic display of expired volume against time (a
spirogram)
Spirometry is a painless test that usually takes less than 10 minutes, although sometimes it is
repeated after taking a puffer medication.
2. How the test done
o To achieve good results, carefully explain the procedure to the patient, ensuring that he/she
is sitting erect with feet firmly on the floor (the most comfortable position, though standing
gives a similar result in adults, but in children the vital capacity is often greater in the
standing position).
o Apply a nose clip to the patient's nose (this is recommended but not essential) and urge the
patient to:
breathe in fully (must be absolutely full)
seal his/her lips around the mouthpiece
immediately blast air out as fast and as far as possible until the lungs are completely
empty
breathe in again as forcibly and fully as possible (if inspiratory curve is required and the
spirometer is able to measure inspiration).
obtain at least 3 acceptable tests that meet repeatability criteria
3. Why the Test is performed
Pulmonary function tests are done to:
Diagnose certain types of lung disease (such as asthma, bronchitis, and emphysema)
Find the cause of shortness of breath
Measure whether exposure to chemicals at work affects lung function
Check lung function before someone has surgery
It also can be done to:
Assess the effect of medication
Measure progress in disease treatment
Risks:
The risk is minimal for most people. There is a small risk of collapsed lung in people with a certain
type of lung disease. The test should not be given to a person who has experienced a recent heart
attack, or who has certain other types of heart disease.

How to Prepare for the Test
Do not smoke for one hour before test
Do not drink alcohol within four hours of test
Do not eat a large meal within two hours of test
Please wear loose clothing
Do not perform vigorous exercise within 30 minutes of test
If you are on puffer medications, you may be asked to not take them for a few hours before
spirometry.

How the Test Will Feel
Since the test involves some forced breathing and rapid breathing, you may have some temporary
shortness of breath or lightheadedness. You breathe through a tight-fitting mouthpiece, and you'll
have nose clips.

What does spirometry measure?
1. Spirometry tells your doctor if your lungs are functioning normally. It does this through
different breathing measurements, some of the most common measurements include:
2. Forced Vital Capacity (FVC) The largest amount of air that you can blow out after you take
your biggest breath in.
3. Forced Expiratory Volume (FEV1) The amount of air you can blow out of your lungs in the
first second.
Considerations
Your cooperation while performing the test is crucial in order to get accurate results. A poor seal
around the mouthpiece of the spirometer can give poor results that can't be interpreted. Do not
smoke before the test

2. 50 yr old gentleman, ex-smoker, presented with SOB. He is a regular pt
in your clinic, he wants to buy himself a nebulizer machine for
convenient sake. Please counsel him.
Check patient understanding regarding home nebuliser
1. What is a nebuliser
A nebuliser is a device that turns a liquid containing medication into a fine mist that you can
breathe into your lungs.
It usually used in severe attack only
However, for most attacks research has shown that using multiple doses of the same
medicine breathed in through an inhaler (usually blue) and spacer is as good as a nebuliser.

2. Using a nebuliser
Its important to use and maintain a nebuliser correctly. Individual nebulisers vary, so he should
follow the manufacturers instructions carefully. He need to know the following:
how to set up the nebuliser
how to keep it clean
how to put the medicine in the nebuliser
when the medicine has finished being nebulised
how to clean the disposable parts
when to change the disposable parts
how and when to change the filter (if there is one)
how to get it repaired.

3. Medications used in nebulisers
Nebulisers are most commonly used to treat asthma and COPD, usually when reliever medication
(drugs that relieve symptoms of an attack or flare up) such as salbutamol, terbutaline or
ipratropium, are needed at a high dose.

4. Precaution
Even if he have used a nebuliser before, its not recommended that he rely on a nebuliser to
self-treat asthma attacks at home as it can be dangerous.
This is because when he has an asthma attack you need to be properly assessed by a doctor
or nurse.
This includes having his pulse, breathing rate and oxygen levels checked.
He might also need additional treatment such as oxygen and steroid tablets.
A higher dose will increase side-effects, which may include palpitations and tremor
(trembling or feeling shaky).

3. 61 yr old lady, smoking for 30pack yr, presented with LOA,LOW for 3
months, looks cachexic and with audible wheeze. Chest x ray showed
left perihilar mass, chest physician requested for bronchoscopy. Please
counsel her.
Introduction and orientation
Check patient understanding regarding bronchoscopy

1. Bronchoscopy
Bronchoscopy is a test to view the airways and diagnose lung disease. It may also be used during the
treatment of some lung conditions. Usually, the test is done as an outpatient procedure and you will
go home the same day. Some patients may need to stay overnight in the hospital.

2. Why the Test is performed
You may have a bronchoscopy to help your doctor diagnose lung problems, inspect the airways or
take a biopsy sample.

Common reasons to perform a bronchoscopy for diagnosis are:
Lung growth, lung cancer, lymph node, atelectasis, or other changes seen on an x-ray or
other imaging test
Suspected interstitial lung disease
Coughing up blood (hemoptysis)
Possible foreign object in the airway
Cough that has lasted more than 3 months without any other explanation
Infections in the lungs and bronchi that cannot be diagnosed any other way or need a
certain type of diagnosis
Inhaled toxic gas or chemical
To diagnose a lung rejection after a lung transplant

You may also have a bronchoscopy to treat a lung or airway problem, such as to:
Remove fluid or mucus plugs from your airways
Remove a foreign object from your airways
Widen (dilate) an airway that is blocked or narrowed
Drain an abscess
Treat cancer using a number of different techniques
Wash out an airway (therapeutic lavage)

3. Risks:
Main risks of bronchoscopy are:
Bleeding from biopsy sites
Infection

There is also a small risk of:
Arrhythmias
Breathing difficulties
Heart attack, in people with existing heart disease
Pneumothorax (collapsed lung)

Risks when general anesthesia is used include:
Muscle pain
Change in blood pressure
Slower heart rate
Nausea
Vomiting

4. How to Prepare for the Test:
Not to eat or drink anything 6 to 12 hours before the test.
Not to take aspirin, ibuprofen, or other blood-thinning drugs before the procedure.
Arrange for transportation to and from the hospital.
Arrange for work, child care, or other obligations, as you will likely need to rest the next day.

5. How the Test is performed
A bronchoscope is a device used to see the inside of the airways and lungs. The scope can be flexible
or rigid. A flexible scope is almost always used. It is a tube less than one-half inch wide and about
two feet long. In rare cases, a rigid bronchoscope is used.
The scope is passed through your mouth or nose through your windpipe (trachea) and into your
lungs. Going through the nose is a good way to look at the upper airways. Going through the mouth
allows the doctor to use a larger bronchoscope.
If a flexible bronchoscope is used, you will probably be awake, but sedated. During the
procedure:
o You likely get medicines through a vein (intravenously) to help you relax. Or you may
be asleep under general anesthesia, especially if a rigid scope is used.
o Numbing drug (anesthetic) is sprayed in your mouth and throat. If bronchoscopy is
done through the nose, numbing jelly will be placed in one nostril.
o The scope is gently inserted. It will likely make you cough at first. The coughing will
stop as the numbing drug begins to work.
o The doctor may send saline solution through the tube. This washes the lungs and
allows the doctor to collect samples of lung cells, fluids, and other materials inside
the air sacs. This part of the procedure is called a lavage.
o Sometimes, tiny brushes, needles, or forceps may be passed through the
bronchoscope to take very small tissue samples (biopsies) from your lungs.
o The doctor can also place a stent in the airway or view the lungs with ultrasound
during the procedure.

6. How the Test Will Feel
Local numbing medicine (anesthetic) is used to relax and numb your throat muscles. Until
the medicine begins to work, you may feel fluid running down the back of your throat. This
may cause you to cough or gag.
Once the medicine takes effect, you may feel pressure or mild tugging as the tube moves
through the windpipe (trachea). Although you may feel like you are not able to breathe
when the tube is in your throat, there is no risk of this happening. The medicines given to
relax you help with these symptoms and will help you forget most of the procedure.
When the anesthetic wears off, your throat may be scratchy for several days. After the test,
the cough reflex will return in 1 to 2 hours. You will not be allowed to eat or drink until your
cough reflex returns.

Take consent for bronchoscopy

4. 53yr old lady, presented with intermittent constipation and stool
overflow, LOA and showed tinged of jaundice. Gastro ppl wants
colonoscopy, please counsel her.
History - elicit symptoms of Carcinoma of colon
change in bowel habit ( diarrhoea/constipation)
PR bleed
persistent abdominal pain
incomplete evacuation of bowel
loss of appetite and weight
weakness and fatigue

Asess risk factor for Carcinoma of colon:
Age >50
African american
History of colorectal cancer/ breast/cervical cancer
Inflammatory bowel disease
Family history of ca colon
Diet- high fat and low fiber diet
smoking and alcohol

Explain procedure of colonoscopy:
(1) What is colonoscopy
specialised examination using a long and flexible tube with video camera to visualise the large
intestine
the doctor can guide the tube safely to the areas to be examine

(2) Indication for colonoscopy
To screen for hemorrhoids, polyps, cancer of colon
to perform treatment/ intervention such as excision or cauterisation of polyp

(3) Preparation/ procedure
Patient will be given medication to clear out the large intestine by defecation one day before the
test
Need to fast/ NBM 6 hours before procedure
Patient to lie flat on left side
Injection of sedative/ pain killer given to make you more relaxed or go into light sleep
continuous oxygen and pulse monitoring
lubricant applied to anus
finger tip examination of anal canal is first carry out
colonoscope gently introduce into anus and steered into large intestine
duration : 15 - 30 mins
in some cases necessary to take sample of the tissue biopsy for examination

(4) Complication of colonoscopy
It is a SAFE procedure but complication can sometimes occur
bloating
gaseous distention
mild abdominal cramp
heavy bleed post removal of polyp - may result in transfusion of blood and reinsertion of
colonoscope to control bleeding
perforation of intestine
risk of sedation causing low blood pressure and oxygen saturation

(5) Post colonoscopy
Rest and observe in recovery bay for 1/2 hour
Advice not to drive or handle heavy machinery on the same day due to effect of the sedatives

(6) Alternative Test
Barium Enema ( XRay investigation by administrating a white liquid through anal canal), however
limitation is not able to perform biopsy in same setting

5. 33 yr old lady presented with PR bleed for 1 week, she has family
history of ca colon. On requesting to do anal speculum examination,
she refuse your examination because she think might be haemorrhoid
only. Please counsel her.
(1) Elicit History of other symptoms of carcinoma colon:
loss of appetite and weight
altered bowel habit ( diarrhoea / constipation)
incomplete evacuation of bowel
abdominal cramps or frequent bloating

(2) Assess of risk factors of carcinoma of colon:
age > 40
history of polyp
underlying inflammatory bowel disease
diet : high fat, low fiber
obesity
smoking and alcohol
underlying previous history of carcinoma colon, breast, cervix
(3) Explain the need to perform proctoscopy- indication:
to examine the anal cavity, rectum or sigmoid colon for screening of cancer, hemorrhoids, polyp

(4) proctoscopy procedure

A proctoscope is a small, rigid, hollow metal tube is first lubricated and inserted into the rectum
Then the obturator is removed

(5) Treatment of carcinoma of colon
surgery + colonostomy
chemotherapy
radiotherapy - especially rectal carcinoma

* screening for colon carcinoma in Malaysia - age > 40-45 yrs with feccal occult blood +ve
for flexible sigmoidoscopy every 5 years
colonoscopy every 10 years

6. 18yr old student presented with on and off dyspepsia, his mother was
worried, please proceed.
Dyspepsia Management based on NICE guidelines
(1) Review medication that can cause dyspepsia
Calcium antagonist
Nitrates
Theophylline
Steroid
NSAIDs
(2) Review alarming symptoms that may suggest carcinoma of stomach, including duration of
Dyspepsia:
Chronic GI bleeding
progressive unintentional weight loss
persistent vomitting
epigastric mass
Iron deficiency anemia
suspicious barium meal result

* If a patient is > 55 years with unexplained and persistent dyspepsia, refer for endoscopy

(3) Reassure mother

(4) Treatment options
For uninvestigated dyspepsia:
PPI
H. Pylori screening - urea breath test/ stool antigen test

For GERD:
Low dose of PPI for 1-2 months
if symptoms reccur- low dose PPI as maintainence dose

Peptic Ulcer Disease:
H. Pylori eradication - PPI + Metronidazole+ Clarithromycin
low dose PPI/ H2 receptor antagonist for 2 months

Endoscopic confirm no ulcer dyspepsia:
treat for H. Pylori if +ve
H.Pylori test after eradication may or may not be repeated

(5) Followup
Annual TCA to review symptoms

(6) Indication for endoscopy
Dyspepsia with acute GI bleed
progressive unintentional weight loss
age > 55 with chronic dyspepsia
difficulty in swallowing, persistent vomitting
epigastric mass
suspicious barium meal results

7. 75 yr old retired private institution headmistress, demented, came
with caretaker, presented with SOB, reduced effort tolerance, bilateral
pitting pedal edema. All children in oversea, the hospital expenditure
is monitored, the eldest daughter want to speak with you regarding
the need of doing ECHO, please proceed.
Starting the conversation, communication skills
Introduce self with established rapport
Established guardians identity and relationship with patient
Ask guardian understanding regarding the procedure and correct misconception
Why the procedure must be done:
The size and shape of your heart, and the size, thickness and movement of your hearts
walls.
How your heart moves.
The hearts pumping strength.
If the heart valves are working correctly.
If blood is leaking backwards through your heart valves (regurgitation).
If the heart valves are too narrow (stenosis).
If there is a tumor or infectious growth around your heart valves.
Problems with the outer lining of your heart (the pericardium).
Problems with the large blood vessels that enter and leave the heart.
Blood clots in the chambers of your heart.
Abnormal holes between the chambers of the heart.
What is echocardiography:
An echo uses sound waves to create pictures of your hearts chambers, valves, walls and the
blood vessels (aorta, arteries, veins) attached to your heart.
An echo cant harm you and commonly done
How was it done:
A probe called a transducer is passed over your chest. The probe produces sound waves that bounce
off your heart and echo back to the probe. These waves are changed into pictures viewed on a
video monitor.
Reassure it is a safe procedure
Ethical issue
Ask for consent and show respects for guardians autonomy

8. A lady came to review her blood results of lipid, glucose and LFT. Noted
dyslipidemia and raised liver enzyme. Proceed your consultation.
Starting the conversation, communication skills
Introduce self, established rapport.
Ask and confirm identity
Ask hows she feeling right now
Getting the basic information
How much she understands about her condition
Sharing information in lay man terms
About her abnormal results.
Statin is not contraindicated if transaminases was less than 3 folds of upper level. It is safe
Obtain further history
Elicit causes for elevated liver enzymes
o Hepatitis B/C. IVDU, Blood transfusion
o Alcohol intake
o Medication related : traditional medicine, anti epileptic. Anti TB meds, anti Hypertensives,
acetaminophen
Ending the consultation
Offer to investigate causes of elevated transminases. Arrange blood test and ultrasound
investigation
This questioned is a bit subjective and lead to multiple possibilities unless it includes the
demographics of the patient and the parameter of the blood test ( LFT / FSL)
These diagrams I guess would be helpful (taken from CPG Dyslipidaemia).

Risk assessment based on Framingham study
Therapeutic Lifestyle Changes if the transaminases were significantly high ( > 3x)
o Dietary Modification- less carbo, oily food,seafood and take more fibres ( cereal, oat)
o Weight reduction: 0.5 -1 kg / week .Waist circumference. <90cm for men and < 80 cm for
women
o Exercise : 4-5 x /week = 30 45 minutes per session
o Ciggarete Smoking
o Alcohol increases plasma TG.
o Male <14 units
o Female <7 units
*1 unit = beer 250 ml/ wine 100 ml/whisky 30 ml

9. 57 yr old gentleman came with letter to FLUP from UMMC, diagnosed
with CCF and recurrent admission for decompensating, he was just
discharged yesterday. Please counsel him.
Communication skills
Introduce yourself and establish rapport
Identify the patients identity
Ask how is he feeling right now
Obtain basic information
Assess his understanding regarding his disease
Provide the information
Gradually let the he absorb and understand
o Take medicine as prescribed
o Advice for low salt diet
o Dietician referral for dietary input
o Read labels and avoid food high in salt and sodium
o Weight consistently per week
o Fluid restriction
o Follow the exercise program cardiac rehab

TCA stat if:
o Worsening Shortness of breathe
o Increasing weight
o Nocturnal coughing disturbed sleep
o Swollen leg and ankles more than usual
o Dizziness or fainting spells
o Greenish or yellowish circles around things
o Feel sick in the stomach
o Tightness in chest, neck or arm
o Less urination
o Your pulse is less than 50 or more than 100
o Side effects from medicine given

Ending the conversation
o Arrangement to see the dietician for diet modification
o Allow Q&A sessions and responds

10. 69 yr old lady presented with sudden onset left sided body weakness
and loss of bowel as well as bladder control. Neuro ppl wants you to
insert NG tube and CBD, please counsel pt and family member.
- Tube feedings are given when person cannot eat enough or drink enough to have adequate
nutrition for the body. Fluid is needed to prevent dehydration and to promote healing
- A nasogastric (NG) tube is a soft, long, narrow feeding tube that goes through the nose and
down into the stomach.
- Before leaving the hospital, patient and family should be able to:
Give yourself liquid food and water through the feeding tube
Give yourself medication through the tube
Take care of the tube
Trouble-shoot problems if they arise

- Equipment needed are:
60cc syringe
Liquid food prescribed by your doctor
Measuring cup
Clean food container
IV pole or wall hook to hang the food container while receiving the feeding (optional in the
home)

- Steps:
1. Always wash hands thoroughly before touching the NG feeding tube, food, or medication.
2. Check the placement of your feeding tube:
Attach a 60cc syringe to the end of your feeding tube.
Pull back on the plunger. You should see some gastric juices (yellow-green fluid). This is
stomach content and tells you the tube is in your stomach.
If you pull back more than 150cc of fluid, do not give yourself food. Inject the stomach
content, which contains important minerals, back into the tube.
Then flush with water. Wait for a few hours and check again.
Tell your visiting nurse or your doctor if this occurs frequently.
3. If stomach content does not show when you pull back on the plunger, you can use another
method to check placement:
Draw up 20cc of air into your syringe.
Insert the air into your feeding tube while holding one hand over your stomach.
Call your doctor if you see no stomach content and feel no air bubbles under your hand. This
may indicate your tube has been displaced.
4. To give yourself the feeding, follow these steps:
Insert the tip of the tube from your food container into your feeding tube.
Open the clamp slowly to adjust the speed of the feeding.
Your meal should last 45 minutes to an hour. It is important to sit up or prop your head up
while receiving your feeding. If you have choking or difficulty breathing during a feeding,
stop the feeding and call your doctor immediately.
When the feeding is done, fill the food container with the amount of water your doctor
prescribes. This provides fluids for you and flushes out the tube.
After the water is given, roll the clamp down to turn off and disconnect the food container.
5. Wash out the food container after each use:
Use dishwashing liquid and water to wash the container.
Rinse the container thoroughly.
Use a clean food container for each feeding.
Giving Medications:
-Medications can be given through your NG tube. Use the liquid form of your medication if it is
available at your pharmacy. If the liquid form is not available, you must crush your pills.
If the letters SR appear after the drug name on the label, this indicates the medication is
sustained-release. Do not crush these pills. Check with your pharmacist or nurse to be sure that
your pills may be crushed and given at the same time.
To give your medication, follow these steps:
Check for feeding tube placement
Flush your feeding tube with 30cc of water before giving your medication.
Crush the pills. To crush your pills, place them in a plastic bag, and then use a rolling pin or
soup can as a crushing instrument. After you have crushed your pills finely, let the pieces
dissolve in warm water (not hot water) so that no pieces will clog your tube.
Draw medication up into your syringe by pulling back on the plunger.
Attach the syringe to the end of the feeding tube. Then push on the plunger to give your
medication.
Flush the tube with 30cc of water after giving your medication.
Some medications should be given with food; others on an empty stomach. Ask your
pharmacist for directions.
Mouth and Tube Care:
Brush your teeth at least twice daily, if your doctor says you may.
Clean the area where the NG tube goes into your nostrils daily. Use a cotton-tip applicator
moistened with warm water. If your nose becomes sore, you may apply water-soluble
lubricant (such as Surgilube or K-Y jelly).
Change your nasal tape every other day or when it is loose.
Make sure the nasal tape is secure at all times. If your feeding tube falls out, call your doctor
as soon as possible.
To prevent a clogged feeding tube, flush your tube with water each time after giving a
feeding or medication.
If your tube becomes clogged, you can use these methods:
Place the syringe into your feeding tube, and pull back on the plunger.
Flush your tube with warm tap water.
If you cannot unclog your tube, call your doctor immediately. It is important not to miss your
prescribed liquid food and water.
When to Call the Doctor
If you choke or have difficulty breathing during a feeding, stop the feeding and call your
doctor immediately.
If you cannot unclog your tube, call your doctor immediately.
If your feeding tube falls out or you cannot confirm that the end of the tube is in your
stomach, call your doctor as soon as possible.
Call your doctor if any of the following last for more than a day: diarrhea, constipation,
nausea, dark urine, bad-smelling urine, dry mouth
Call your doctor if the tube seems to be moving farther out.

CBD INSERTION
- A catheter is a hollow, flexible tube that drains urine from your bladder.
- Two ways to fit urinary catheters are through your urethra (the tube through which
urine passes); or through a channel in your abdomen wall (a suprapubic catheter).
- There are many reasons why people need a catheter. Your bladder may not be able
to contract on its own to empty itself.
- The way that your catheter is inserted (urethrally or suprapubically) will depend on the
reason and length of time that you need a catheter.
- Once the catheter is in place, a balloon is inflated inside your bladder, to prevent it from
falling out.
- Your catheter will be attached either to a leg bag or a valve :
A leg bag is a simple drainage bag that is strapped to your leg and collects your urine and
will need emptying at regular intervals.
With a catheter valve, your urine collects in your bladder, which can be
emptying at regular intervals by releasing the valve.
- Both options should be explained to you, as well as how to operate them. The bag or valve
needs changing every five to seven days. It is important that you do not change them more
often, because this raises the risk of infection.
- When you go to bed at night, you should attach the leg bag or valve to a larger bag, which
will drain freely overnight to collect the urine. If you are prone to swollen legs or have poor
circulation, loosen the Velcro straps on the leg bag, so that they do not constrict the blood
flow to your leg. In the morning, disconnect the night bag, empty it and store it in a clean
place until you reconnect it. This bag should also be changed every five to seven days.
- You will be given supplies when you leave the hospital and told how to get further products.
- You will be asked to give your verbal consent (agreement) to have a catheter.
- The catheter may feel uncomfortable at first. You could experience spasms (sudden
contractions of your muscles) which can be painful, make you feel like you need to pass
urine and cause some urine to bypass the catheter and leak out. This is your bodys way of
trying to expel the catheter from your body.
- If you have spasms:
try repositioning the catheter so that it is not pulling on your bladder
try to relax
do not strain or try to push the catheter out
drink plenty of fluids

Hygiene
- Before and after touching your catheter you must make sure that you always wash your
hands thoroughly.
- You can bathe or shower as normal with a catheter.
- If you have a leg bag, do not disconnect it, as this could introduce an infection.
- If you are not able to have a bath or shower, wash the area where the catheter enters your
body twice a day.
- Wash the area using downward strokes from where it enters the body; again, this is to help
prevent infection.
- Do not apply talcum powder or cream to the area as this may also increase the risk of
infection.
Your Diet and Fluids
- It is important to eat a balanced diet of fruit, vegetables and fibre to avoid constipation
(difficulty or pain emptying your bowels). If your bowel is full, which can happen when you
are constipated, it can press on your bladder and reduce urine drainage and may block the
catheter.
- Drinking is very important when you have a catheter. Try to drink at least one and a half to
two litres per day (six to eight large glasses of fluid). This will help prevent infections and
flush out any debris in your bladder.
- Drinking alcohol will not affect your catheter. However, if you are taking certain medicines
or recovering from surgery, you may be advised against drinking alcohol.
Can I work and exercise as normal?
- You can return to work, exercise or go on holiday as soon as you feel able to and are fit
enough.

Having sex
- If you were sexually active before having a catheter fitted, you should be able to have sex
with one in place.
- You can leave the catheter in place, but once you have an erection, fold it under your penis
and apply a condom over your penis and the catheter. You can use lubricating jelly if you
need. It will not damage the catheter. Always wash around your catheter after having sex.

Are there any risks with having a catheter?
- You may have a slightly increased risk of developing urinary stones or a urinary tract
infection.

11. 14yr old boy presented with abnormal generalized body movement
with loss of consciousness for past 2 months, mother told no family
history of seizure. The family just move to new house for nearly
3months. Neuro ppl wants you to do EEG before referring. Please
counsel.
- An electroencephalogram (EEG) is a test used to evaluate the electrical activity in the brain.
Brain cells communicate with each other through electrical impulses, and an EEG can be used to help
detect problems associated with this activity.
- An EEG is used to detect problems in the electrical activity of the brain that may be
associated with certain brain disorders. The measurements given by an EEG are used to confirm, rule
out, or provide information about disorders such as:
seizure disorders, including epilepsy
head injury
encephalitis, or inflammation of the brain
brain tumor
encephalopathy, or brain dysfunction resulting from various causes
memory problems
stroke
sleep disorders
- An EEG can be used to monitor activity during brain surgery. It is also performed to
determine the level of brain activity in someone who is in a coma.
- An EEG cannot provide a measurement of intelligence and is not used to diagnose mental
illness.

How Is an EEG Done?
Electrical impulses in the brain are evaluated using an EEG. The test measures this electrical activity
through several electrodes placed on your scalp. An electrode is a conductor through which an
electric current can pass safely. The electrodes transfer information from your brain through wires
to an amplifier and a machine that measures and records the data.
The test is administered at a hospital, at your healthcare providers office, or at a laboratory by a
specialized technician. The test usually involves the following steps:
You will be asked to lie down on your back in a reclining chair or on a bed.
The technician will measure your head and use a pencil to mark where electrodes will be
attached to your scalp. These spots are then scrubbed with a special cream that helps the
electrodes get a high-quality reading.
The technician will put a sticky gel adhesive on 16 to 25 electrodes and will place these
electrodes at various spots on your scalp. The electrodes look like flat metal disks.
Once the test begins, the electrodes send electrical impulse data from your brain to the
recording machine. This machine converts the electrical impulses into visual patterns that
can be seen on a screen and are saved to a computer. On the screen, the electrical impulses
look like wavy lines with peaks and valleys.
You may be directed by the technician to do certain things while the test is in progress, such
as lie still, close your eyes, breathe deeply or quickly, or look at stimuli like a flashing light or
a picture.
The EEG usually takes 30 to 60 minutes.
After the test is complete, the technician will remove the electrodes. During the test, very
little electricity is passed between the electrodes and your skin. The electrodes do not send
any sensations, and you will feel little to no discomfort.
There are no risks associated with an EEG. The test is painless and safe.

The following should be done prior to having an EEG:
Wash your hair the night before the EEG and do not put any products, such as conditioners,
sprays, or gels in your hair before the test.
Check with your doctor to see if you should stop taking any medications before the test and
bring a list of your medications to give to the technician performing the EEG.
Avoid any food or drinks with caffeine for eight hours prior to the test.
If you are required to sleep during the EEG, your doctor may ask you to sleep as little as
possible before the test. Also, you may be given a sedative to help you to relax and sleep
before the test begins.
After the EEG is finished and the technician removes the electrodes from your scalp, you
should not feel any side effects from the test, and you can continue with your regular
routine for the day.
However, if you were given a sedative, the medication will be in your system for a short
while. You will need someone to take you home after the test, and you will be instructed by
the technician to rest and not drive for the rest of the day.
A specialized doctor interprets the recordings taken from the EEG and then sends the results
to the doctor that ordered the test for you.
Normal Results
Electrical activity in the brain is seen in an EEG as a pattern of waves. Different levels of
consciousness, such as sleeping and waking, have a specific range of frequencies of waves per
second that are considered to be normal. For example, the wave patterns move faster when you are
awake than when you are asleep. The EEG will show if the frequency of waves or patterns are
normal.
Abnormal Results
Abnormal EEG results may be due to:
epilepsy or other seizure disorder
abnormal bleeding or hemorrhage
sleep disorder
swelling of the brain or encephalitis
tumor
problems with attention
death of tissue because of a blockage of blood flow or cerebral infarction
migraines
alcohol or drug abuse
head injury

12. 22 yr old student, just came back from india for semester break for the
first time. Before coming back he had episodes of watery diarrhoea.
Today presented with progressive lower limb weakness started this
morning. Neuro boss wants you to do EMG and NCS, please counsel pt.
- Electromyography (EMG) is a diagnostic tool that evaluates muscle or nerve problems. It
uses surface electrodes to assess the ability of motor neurons (the nerve cells that control your
muscles) to transmit electrical signals. It also uses needle electrodes to evaluate your muscle activity
when at rest and when contracted.
- Some symptoms that may call for an EMG include:
tingling
muscle weakness
numbness
muscle pain or cramping
paralysis
involuntary muscle twitching

- Conditions that may cause these symptoms could include:
muscle disorders (such as muscular dystrophy)
disorders affecting the ability of the motor neuron to communicate to the muscle (such as
myasthenia gravis)
peripheral nerve disorders (such as carpal tunnel syndrome), which affect nerves outside the
spinal cord
nerve disorders like amyotrophic lateral sclerosis (ALS, also known as Lou Gehrigs disease)

- If you have a pacemaker or implantable defibrillator, or if you suffer from a bleeding
disorder or lymphedema, you may not be able to have an EMG.
- If you are able to have an EMG, you should do the following beforehand:
Dont smoke for at least three hours before the exam.
Bathe or take a shower to remove any oils from the skin and dont apply any lotions or
creams after washing.
Wear comfortable clothing that does not obstruct the area that your doctor will test. You
may also be asked to change into a gown.

- The EMG usually has two parts:
a nerve conduction study, which uses electrodes taped to your skin to evaluate your motor
neurons
a needle electrode exam, which uses a small needle inserted into your muscles to evaluate
your muscles electrical activity
- During the EMG, you will lie down on an exam table or recline comfortably in a chair. Your
doctor may ask you to move into different positions during the exam.
- Some patients report pain and discomfort during an EMG. If at any point the test becomes
too painful, you can ask your doctor to take a break.
- The entire procedure should take between 30 and 60 minutes.
Nerve Conduction Study
- During this part of the procedure, your doctor will apply several small electrodes to the
surface of your skin. This will evaluate how well your motor neurons communicate with your
muscles.
- The electrodes will deliver electrical stimuli to your nerves, and the information is
transferred to a small computer as waveforms.
- You may feel a tingling or twitching sensation during this portion of the test. Once the test is
complete, the electrodes are removed.
Needle Electrode Exam
- Next, your doctor will sterilize specific parts of your body and insert a small, thin needle. You
may feel slight discomfort or pain while the needle is being inserted.
- The needle electrodes evaluate electrical activity in your muscles, both when at rest and
when contracted. The computer translates this electrical activity visually as waveforms and
audibly as popping sounds.
- Once the test is complete, the needle electrode is removed.

What Risks Are Involved?
- An EMG is a low-risk exam. Some patients may feel soreness in the areas being tested. This
may last for a few days and can be relieved with an over-the-counter pain reliever.
- Some patients also report tingling, bruising and swelling at the needle insertion sites. While
the risk of infection is low, you should tell your doctor if the swelling or the pain grows
worse.

After the EMG
- The results of the your test can be reviewed almost immediately with you and further steps
of management will be discussed accordingly.

13. Pakcik Harun is your regular pt FLUP in DM clinic, puasa month is near,
he had history of hypogycemic attack last year. He also had dementia,
currently he is on mixtard 20U BD. His son also DM, on actrapid 10U
TDS, insulatard 14U ON, please counsel both of them.
1. Greets patient and introduce yourself
2. Ask about specific symptoms:
intercurrent illness
hypoglycemic attack(swaeting, palpitation,cold peripheries,giddy attack,blackout)
3. Ask about medication:
Mixtart 22U om, 18U on.
Ask for compliance, can her remember
Who serve the medication
4. Elicit patients understanding of present medication
Why is he on these medication
Whether doing SMBG(fasting:4-6, pp:6-8)
5. Educate him the risk of fasting during ramadhan(hypo, damage to brain, death)
In view previous hx of hypo attack
Aware of signs & symptoms of hypo
management of hypo(take sweet drinks, recheck reflo after half an hour)
dangerous of hypo attack
6. If pt insist on fasting, then adjust his insulin timing
morning dose 18U given at sahul, night dose 22U is during breaking fast. (larger dose at night
because that time usually take heavy meal, and some ppl take supper)
For his son, the dosage will be:
Actrapid 10U morning, skip afternoon dose actrapid, evening actrapid 10U and insulatard 14U night.
7. Check reflo regularly, pre-meal and afternoon.(if sugar<4, >15 then better to terminate
fasting and visit dr)
8. Pt may come again anytime if he is still not sure or forgot the adjustment.

14. Encik Johan came with BP: 170/90, he told you his home BP is only
140/90, therefore he cut down his medication to half. Please counsel
him on home BP monitoring.
2. Ask about specific symptoms:
Headache, blurring of vision, giddiness, sob, chest pain indicates pt might be having hpt crisis, and he
needs to be rest in bed and regular bp monitoring. (KIV give adalat if bp increasing in trend)
3. Ask about medication:
Whether correct dosage. (amlodipine10mg, cut down by himself to 5mg)
Shall not adjust dosage by his own, need to consult dr first.
4. Elicit pts understanding of current medication:
The need of taking medication(reduce risk of stroke, heart attack, prevent target organ
damage)
Tell the risk of high bp(paralysed, coma and death)
5. Elicit whether he knows the proper way to check bp:
What type of bp apparatus(electronic, manual)
Choose the right size(80%length, 40%width covering the arm), placed at heart level
Seated at least 5min, without smoking, meal, caffeine in take or physical activity for at least
30mins.
Seated in a quiet room, back supported, arm supported.
Seated with leg uncross, not talking and relax.
Minimum measure 3days a week, but ideally daily.
Done at same time daily once in morning(before drug) and evening(before meal) readings
should be taken with two measurements per occasion(1-2min apart),the higher reading
should be taken as the systolic bp.
Systolic bp>135mmhg, diastolic>85mmhg consider elevated.
Systolic bp<130mmhg, diastolic<80mmhg consider normal.
Result should immediately recorded.
6. Need to FLUP and do not default treatment.
7. Can come back to ask if not sure.
8. To bring his electronic bp apparatus next visit to counter check with manual mercury bp
apparatus. To determine whether need calibration, or else need to buy a new one.

15. 20 yr old lady came to see you, she presented with minimal PV
discharge, she think it is abnormal because before having SI with her
BF she doesnt have such symptoms before. Please counsel her.
2. Ask date of onset, relation to menses and coitus.(discharge more during premenstrual and at
time of ovulation)
3. Amount, consistency, odour, color.(excessive, unusual color, offensive odour might be due
to infection)
4. Associated symptoms-itchiness, pain, swelling, fever, urinary symptoms.
5. Any previous hx of treatment.
6. Partner-any urethral or penile discharge(suggest STI)
7. Contraceptive usage-IUCD,COCP.(may increase PV discharge)
8. Sexual hx from pt and bf, any risk of STI.
9. Hygiene practice-douching, tampon use.
10. Any other medical disorder such as diabetes, and also ask about partners medical problem.
11. Inform pt regarding the possible causes of PV discharge(physiological, infection, cervical
polyps/fibroid, allergy secondary to douching/use of lubricant/soaps, malignancy.
12. Ask permission to do physical examination.(external genitalia, speculum, bimanual exam)-
TRO malignancy, benign growth
13. Also suggest further test(pap smear, HVS c&s, USG, FBS)
14. If hx suggestive of infection to start Rx while waiting for result.(im rocephine 1g stat,
t.azithro 1g stat)
15. If hx suggestive of physiological/contraceptive induce discharge then advice pt stop
hormonal type of contraceptive and use barrier method. Advice hygiene, avoid frequent
douching. Give TCA to rv result.
16. If pt has any doubt can come back again.

16. 18 yr old lady came for FLUP of her pregnancy, her HIV test showed
positive, please counsel her.
1. Introduction
- Introduce yourself:
Good morning, I am Dr. L, doctor in charge of you.
- Check patient identity:
May I know you are?
- Explain Role/purpose of meeting:
Do you know why you are here today?
I understand that you come here today for the HIV testing results
-Explore understanding:
Before I proceed, may I know your understanding about HIV/AIDS?
-Explain about the disease/correct any misconception

2. Break the bad news
- Explore the condition since testing:
How do feel after the HIV testing? (e.g. worry, anxious)
-Give warning shot:
I am afraid I have got some bad news to share with you .. pause
-Break bad news:
Your HIV testing results came back as positive
-Express sympathy:
I am sure this must be difficult for you
Offer tissue
Are u ok?
-Identify concerns & address it:
May I know what your concerns are at this moment?

3. Problem Definition/Diagnostic evaluation
- Difference between HIV and AIDS
-Consequences of HIV if not treated:
e.g. increase the risk of mother-to-child transmission (MTCT)

4. Management
-Choice of treatment: Aim to stop viral replication & prevent MTCT
Short term antiretroviral therapy (START) /HAART
-Importance to comply with treatment
-Possible complications of treatment
GI: oral ulcers, dry mouth, diarrheoa, vomiting
HBS: jaundice, hepatitis
Neuro: headache, dizziness
MS: myopathy
Skin: dryness, rash
-screening of other STD
-Regular follow up:
Complications, CD 4 (measure the strength of immune systems), plasma viral load
-Transmission & hence safe sex
-Informing partner & support group
-Notify & contact tracing
-Assess support:
May I know who are u living with?
How about your work/study?
-Refer social welfare for teenage pregnancy/ ? single mother

5. Closing
-Ensure confidentiality
-Offer patient to ask questions:
Have u got any questions?
-Set up for next appointment

17. 25yr old lady, k/c of epilepsy on carbamazepine, came to review her
sputum AFB result, all 3 smear positive. Please counsel her.
1. Introduction
May I know you are?
I understand that you come here today to review your sputum AFB results
Before I proceed, may know your understanding about Tuberculosis?
-Explain about the disease/correct any misconception
Pulmonary Tuberculosis is a kind of bacterial infection in the lung which required multiple drug
combination for effective treatment.
Adherence of treatment is re-emphasized.

2. Explain the results of sputum AFB, TB treatment & possible interaction anti-TB medications
-Explain the results
I am sorry to inform you that the sputum AFB smears results turn to be positive, which means that
you are having pulmonary tuberculosis.
-Offer hope
Fortunately, due to advancement of medicine, there are effective treatments available to cure the
disease
-Explain the treatment plan (patient education about the disease, duration of treatment, possible
side effects & monitoring, notification & contact tracing) & emphasize on compliance
The TB treatment consists of combination of multiple drugs regimen and duration of therapy will be
at least of 6 months, in which 2 months will be intensive phase & 4 months will be maintenance
phase.
Before commencing treatment, we will need to send your blood to check your liver function, full
blood count & renal function and send you for baseline eye assessment
Is your house or working place has nearby clinic? As I explained to you before, adherence to
treatment is the key of successful treatment; the nearby clinic is available for you to collect the
medications daily for 2 months, which we call directly observed therapy (DOT).
I understand that you are currently on carbamazepine (your anti-epileptic drug), there may be some
drug interaction with the anti-tuberculous medications, one of the anti-TB drug, Isoniazid
(cytochrome P450 isoenzyme inhibitor) which may increase the carbamazepine levels & leads to
toxicity.
We might need to readjust the dosage of carbamazepine (e.g. reduce the dose) & monitor closely for
the carbamazepine toxicity e.g. ataxia, nystagmus, diplopia, headache, vomiting, apnoea, seizure &
coma.

*Rifampicin (enzyme inducer) , Isoniazid (enzyme inhibitor )
*Carbamazepine (enzyme inducer)
One case report of increased level & toxicity of carbamazepine when Rifampicin & Isoniazid are
given together, probably by inhibition of carbamazepine metabolism by Isoniazid

* Other side effects of anti-TB medications are as below:
Anti-tuberculosis agents Possible side effects Ways of monitoring
Isoniazid 1. polyneuropathy
2. Hepatitis
3. Allergic reaction- rash & fever
4. Enzyme inhibitor

Liver function test

Rifampicin 1. Pink staining of body secretion and
urine.
2. Hepatitis
3. Allergic reaction- rash
4. Enzyme inducer
5. Trombocytopenia (rare)

Liver function test

Full blood count
Pyrazinamide 1. Hyperuricaemia & gout
2. Hepatitis (rare)
3 Allergic reaction- rash
4. Arthralgia
Serum uric acid
Ethambutol 1. Optic retrobulbar neuritis Baseline examiniation of
visual acuity/ refer to
ophthalmologist for
baseline fundoscopy
Streptomycin 1. Ototoxicity 8
th
nerve palsy
2. Nephrotoxicity

Besides, we will need to see you regularly for monitoring of treatment, any possible side effects
We will also need to notify the disease to the authority in order for them to do contact tracing. By
the way, anyone that lives with you is sick?
-Assess support:

3. Closing

18. G2P1 at term, unbooked, estimated 4kg baby, counsel pt for LSCS.
1. Introduction
May I know you are?
I understand that you come here today to discuss about LSCS
-Ask whether husband/friends around to accompany
Before I proceed, may know your understanding about your condition & LSCS?
-Explain about the macrosomia/correct any misconception

2. Explain the indication, what is LSCS, the procedure (before, during & after) & possible
complication of LSCS
-Indication
Madam X, Do u know why we need to do the LSCS to you? This is because we found out from our
scan that your baby estimated fetal weight is 4kg, we are afraid that if you deliver normally, the baby
shoulder will stuck, a condition what we call shoulder dystocia, it can cause the collar bone to be
broken, or nerve injury causing the arm become paralyze
-What is LSCS
Is surgical procedure in which baby is born through an incision made in the mothers abdominal wall
and the wall of uterus.
-The procedure
The patient is given spinal or epidural anaesthesia for the procedure or may have a general
anaesthetic
A horizontal cut is made through the lower abdomen into the lower end of uterus, across the bikini
line. These incisions heal better and are less likely to be associated with complications in future
pregnancies.
The baby is born through the incision- head first. Forceps might be used to help lift out the babys
head
Amniotic fluids in wiped from the babys nose & mouth before its body is lifted free from the uterus.
The placenta is then removed
The patient is then given an injection of oxytocin to make the uterus contract & minimize blood loss
The uterus, tissue layer and overlying skin are then stapled or stitched together
-Recovery
If you have a caesarean section, you will probably have an intravenous drip for the first 24 hours or
so, until you can eat and drink normally.
You can start drinking fluids as soon as you feel able, although you must pass wind before you can
start eating again (it is a sign that your bowel has begun to work normally again).
You might also have a catheter to drain urine from your bladder so there will be no need to get out
of bed to go to the toilet. This is usually removed after you can walk.
You may also have a tube to drain fluid from the wound.
You will be prescribed painkillers, and the midwife and doctor should check regularly to see that
they are working.
As sensation and movement return after surgery, usually within about eight to twelve hours, you
should get out of bed and try to walk around. If you start moving soon after the procedure, this will
speed up recovery and help to prevent certain complications such as blood clots.
The wound dressing should be removed after 24 hours and the scar should be kept clean and dry
once it is exposed.

-Complications
post-surgery infection or fever
too much blood loss
injury to organs
emergency hysterectomy
blood clot
reaction to medication or anesthesia
emotional difficulties
scar tissue and difficulty with future deliveries
death of the mother
harm to the baby

3. Addressing the issue of unbooked
-Explore why is unbooked
I understand that you never book your pregnancy this time. Any particular reason for that?
-Explore supports
-Explain our approach of unbooked case & investigations for macrosomia
We will need to take detailed history, perform physical examination on you.
We will also need to send the blood samples for viral screening, VDRL, OGTT (to look for causes of
macrosomia)

4. Closing
-Get the consent

19. 30 yr old primed, unbooked, vaginal scan showed major PP, now she is
at 37weeksPOA, please counsel for LSCS.
greet and introduce yourself
establish rapport
confirm gravidarum & parity, EDD
ask for spouse to be present during consultation
asks for symptoms of pv bleeding, fetal movement, symptoms of labour
inform the findings of uss: major placenta praevia (at the same time ask whether any uss done
previously)

explained:
- placenta praevia is a low-lying placenta ie it lies in the lower segment of the uterus with 2
types; minor ( edge of placenta encroaching lower segment but does not cover opening of
the womb-path where the baby comes out(cervical os)) and major placenta covering the
opening of the womb, therefore the baby cannot comes out normally).
- it is confirmed low-lying if uss at 32 wks of gestation and above still shows low-lying (it
won't go up)
- for these cases, because it covering the cervical os the way to deliver the baby is through lscs
explained regarding the lscs
- it is a major operation, so will be done in ot and usually it lasts less than an hour if no
complications
- anaesthetics will be given by anaest; can be either GA or spinal (anaest will see her prior to
the op day)
- it is a sterile technique, first we will clean the skin, then incision ~ 15cm made at suprapubic
area, cut layer by layer until reach the womb, then a small incision will be made, baby will be
delivered together with placenta, after that we will suture layer by layer.
- the baby will be seen immediately after delivery by paeds stand by (as with GA risks of fetal
distress)
- complications:
immediate
1. higher risk of bleeding after delivery, this is due to placenta is located in the lower segment
of uterus which unable to contract effectively ---> if this happen then blood transfusion
might be indicated depending on the severity, oxytocin a medication to help with uterine
contraction will be given after delivery of the baby
2. sometimes there is difficulty in delivering the baby, might use instruments (forcep) ---> this
might cause scratch to baby skin (can happen) or in very difficult situation might cause
fracture of clavicle (very rare)
3. injury to internal organs (colon, bladder) but also rare ~1% (higher risk as with 2nd lscs and
so on)
post-operative
1. sometimes bleeding can occur few hours after completed lscs or within 6/52
postpartum(endometritis--need to seek medical attention)
2. infection (fever, abdominal pain, redness or dischage at wound area) ---> will treat this witn
antibiotics and might prolonged the hospital stay
3. VTE ---> we try to prevent it by early mobilization, usually at day 1 post-op
4. UTI
long-term
1. future pregnancy; risks of scar dehiscence during antenatally (very rare) or during labour
(also rare), morbid adherence of placenta (placenta accreta), or recurrence of placenta
praevia(at scar area)

advice: wound care-clean and dry wound dly, after lscs there is no increase risk of difficulty in BF,
dyspareunia, or depression
also advice not to get pregnant at least 2 years, this is to give time for the wound to completely
heal and strong enough for the next pregnancy + offer to use contraception (brief)

*addition: if to counsel mode of delivery after 1 lscs,
1. inform there are 2 choices; VBAC (provided no issues for that pregnancy ie no indication for
lscs) or LSCS
2. as for VBAC, there is a risk of scar dehiscence especially during labour as uterus is
contracting ~0.5%. If there is an indication to induce or augment labour the risk increase (1%
for oxytocin and 2% for prostin)
3. if they opted for lscs, the next pregnancy would be lscs and usually we only allow for 3 lscs
(as risks of internal organ injuries n bleeding much higher due to adhesion

20. G3P2, 1 previous scar with one VBAC, please counsel her for mode of
delivery, now she is 36weeks POA, bb is 3.5kg from scan. Her height is
140cm.
Greet and introduce yourself
- Establish rapport, confirm correct patient
- Ask further history regarding previous pregnancy (especially birth weight of previous 2
babies, indication for previous of LSCS, any complication following LSCSespecially
prolonged hospital stay)
- Enquiry regarding GDM in this pregnancy or pre-existing DM
- Inform the USS finding: EFW 3.8kg (normally EFW by 36 wks POG ~ 3kg +/- 400-500mg)
#If there is fetal growth chat with all parameters, to plot in all the parameters especially AC as this
tells us whether LGA or not
- Ask patient whether she wants her spouse to be with her or not (as the decision for mode of
delivery most of the time involving discussion with the spouse)\

**by assuming this is non-diabetic pregnant lady,
- The baby might be large for gestation, however it is through the USS which have it variation
+/- 400-500mg and also it is operator-dependent
- Having said that, as her height is 140cm there might be risks of cephalopelvic disproportion
or shoulder dystocia
- Due to that, we give an option to the patient; either vaginal delivery or LSCS
- Each of those carries its own risk;

as with vaginal delivery, as mentioned before
1, shoulder dystocia that can cause brachial plexus or facial nerve injury, fracture of humerus
or clavicle
2, risk of 3rd/4th degree vaginal tear

as with LSCS, as this is the 2nd LSCS,
1, the complication risks will increase compared to 1st LSCS ie bleeding and internal organ
injury. Other complication would be infection. Complication to the baby is the same; if use
instrumental delivery then scratch to the babys skin, risks of fracture while delivering the
baby if difficult.
2, for the next pregnancy risk of scar dehiscence and morbid adherence of placenta with
placenta praevia increase and mode of delivery would be LSCS. Usually we only limit LSCS 3
times as the risk of LSCS complications increases with 4th pregnancy.

- the decision for mode of delivery relies onto patient
- if they opted for vaginal delivery, inform that we will shorten the time of labour ie if the
labour fails to progress as expected, then we will proceed with LSCS (because we anticipate
CPD), and also not for instrumental delivery

**if GDM or pre-existing DM,

21. 20yr old student presented with abd pain and PV bleed for 1 week,
admit took pill from GP for abortion. USG showed 9weeks size GS, no
FH. Big boss ask to counsel for D&C.
greet and introduce yourself
establish rapport, confirm name (correct pt)
enquire regarding marital status (if she is married ask whether she wants her husband to be
present)
explain regarding the working dx ie abortion
inform that need to do D&C which is a procedure to clear out PoC from uterine lining, if not done
the bleeding won't stop and it can worsens as the source is there and also they can end up with
infection
explain the procedure:
-need to fasting at least 6 hours before procedure
-it will be done in the ot
-anesthesia will be given prior to the procedure either spinal(most common) or GA
-pt will lie on her back in a lithotomy position (same position as when to deliver the baby)
-the private part will be clean and drape
-put a speculum to open the vagina as to visualize the cervical os and to smoothen the procedure
-insert a thicker rod into cervix and slowly dilate the cervixuntik it is adequately open
-measure the uterus using uterine sound (so that we know how deep we can go during the
procedure)
-curette (spoon-shaped instrument with sharp edge/suction) inserted and scrape the wall of the
uterus for the poc (from all direction 360 degree of the womb) until the can feel like scrapping an
irregular surface (which is a sign that poc removed)
-usually after all poc removed the bleeding will be so much reduced (another sign poc was removed
completely)
-then clean the private area and sent pt to recovery room (for monitoring of anaesthetic effect)
-usually it takes only 15-20 minutes without complication

usually it is a very safe procedure, but rare complications that can occur:
1. perforation of the uterus (this is a rare cx but must mention to pt) ---> if it happens, depending on
severity either repair it laparoscopically (small 3 scars) or laparotomy
2. injury to cervix (can suture if indicated /just apply pressure)
3. infection; endometritis ---> if it happens will treat with antibiotics
4. Asherman syndrome (scar tissue on the uterine wall); can cause amenorrhoea/abnormal/painful
menses, future miscarriage,infertility (but this is very rare)

normal side effect after the procedure: mild abdominal cramp and light pv bleeding or spotting
can resume normal activities within 1-2 days
menses usually resume quickly after that --most within 6/52
nothing should be placed in the vagina for 2/52 following D&C s to prevent introduction of
infection to uterus (cervix might still be open) including SI and tampon
inform that they can conceive after D&C (if no complication of Asherman syndrome)
pertaining to this case, offer contraception (all are applicable) and if not married with multiple
partner, offer condom as well
safety-netting: if presence of those below after the procedure to seek immediate medical
attention
1. heavy bleeding
2. light bleeding more than 2/52
3. fever
4. abdominal cramp more than 48 hrs(or worsening)
5. foul-smelling discharge from vagina

*if questions regarding couple who wishes for a baby, then inform that they can try to conceive
22. G5P4 lady collapse in LR, after delivered 4.2kg bb, her first bb ws born
via LSCS for PP major. Big boss think she might have retained placenta
since only half of the placenta came out after 20min, he wants you to
counsel the husband.
Manual removal of placenta
Occur during 3rd stage of labour
Indication:
All or parts of placenta has not undergone expulsion within:
1. 30 min : active 3rd stage using uterotonic drugs
2. 60 min: physiology 3rd stage without uterotonic drugs
Causes of retained placenta
Placenta separated but undelivered
Placenta partly or wholly attached
Placenta accrete
Technique
Right hand covered with antiseptic cream is introduced into vagina, following the cord
The fingers begin to separate the placenta from the uterine wall
Left hand at the abdomen presses the uterus into the placenta and prevent tearing of the
lower segment
The placenta is inspected at once to see that it is complete and if there is any doubt, the
uterus is re- explored
Ergometrine or oxytocin is given
Massage uterus to make it contract

Complication
Infection
Postpartum bleeding

Approach to menorrhagia
Menstrual History
Duration : 2-6 days
Amount : less than 80mls
Cycle : 21-35 days
Associated symptoms
Dysmenorrhea
PMS
Anemia symptoms
Dyspareunia
History
Menarche
LMP
Contraception methods: hormonal pills/ IUCD/implanon
Drugs/ medication : heparin/ warfarin
Previous pap smear test
Previous medical history: bleeding disorders/ platelet disorder/ thyroid
disorder/hyperprolactinemia
Previous obstetric history
Previous gynaecology history: PCOS/Fibroid
Family history of cancer
Lifestyle: stress/ exercise/ weight loss
Terms/definition:
Menorrhagia: excessive uterine bleeding that occur regularly
Metorrhagia: heavy bleeding at irregular times
Polymenorrhagia: frequent, heavy but regular bleeding occur less than 21 days
Oligomenorrhagia: reduction in frequency of menstruation with interval duration more than
35 days

23. 30 lady CEO of law firm came for family planning counselling, she
wants something easy, not pills and not messy. You suggest implant,
counsel her.
Implanon
Long term reversible contraception
Progestrogen only implant
Contains 68 mg etonogestrel
Lasted for 3 years
Failure rate 0.05%
Failures are due to improper placement, drug interactions or conception prior to method
insertion
Mechanism of action:
Suppress ovulation
Making endometrium and cervix hostile environment to sperm penetration
Timing of insertion
During 1-5th day of menses
If insertion done after recommended timing, extra protection should be advised within first
1/52 and do urine pregnancy test to exclude pregnancy
Technique of insertion
Clean area with antiseptic
Local anesthesia with lignocaine is given around insertion site
Inserted subdermally at inner side of non dominant upper arm about 8-10 cm above medial
epicondyle of the humerus
Puncture the skin with the tip of needle angle at less than 30 degree
Lower the applicator to a horizontal position. While lifting the skin with the tip of the needle,
slide the needle to its full length
While keeping the applicator in the same position and the needle inserted to its full length,
unlock the purple slider by pushing it slightly down
Move the slider fully back until its stops
Verify the presence of the implant in arm immediately after insertion by palpation
Apply a small adhesive dressing with pressure bandage to minimize bruising
Technique of removal
Locate the implanon by palpation
Clean area with antiseptic
Local anesthesia given around removal site
Use scalpel and make incision at edge of implanon
Push implanon with fingers gently towards the incision
Grasp the end of implanon using forcep
Remove the implanon gently
Advantage
Suitable for women with compliance issue
Suitable for women with contraindication to estrogen containing contraceptive
Quick return to fertility within 6/52 of removal
Safe during breastfeeding
Disadvantage
Menstrual pattern alteration amenorrhea/ spotting/ heavy/ prolong
Weight gain (less common)
Mild headache (less common)
Nausea (less common)
Acne (less common)
Infection
Scar at insertion site
Pain/ bruising at insertion site
No STD protection

Usually present during first 6-12 month use. Reassurance should be given and majority of these
problems will disappear with time.
Follow up
1/12 after insertion then annually

24. 45 lady came with 1month of menorrhagia, please proceed.
Classification of menorrhagia
UNDERLYING
CAUSE CHARACTERISTICS TREATMENTS
Ovulatory
Cyclical, might be associated with premenstrual
symptoms or dysmenorrhea
Nonsteroidal anti-inflammatory
drugs
Antifibrinolytics
COCPs
Endometrial ablation
Hysterectomy
Anovulatory
Irregular bleeding, often heavy
More common in adolescents and perimenopausal
women
Higher risk of endometrial hyperplasia
COCPs
LNG-IUS
Cyclic progestins
Androgens
Gonadotropin-releasing
hormone agonists
Endometrial ablation
UNDERLYING
CAUSE CHARACTERISTICS TREATMENTS
Hysterectomy
Anatomic
Caused by fibroids, polyps, or adenomyosis
Often heavy bleeding, pain
Uterus might be enlarged
COCPs
Antifibrinolytics
LNG-IUS
Androgens
Gonadotropin-releasing
hormone agonists
Uterine fibroid embolization
Myomectomy
Hysterectomy
COCPscombined oral contraceptive pills, LNG-IUSlevonorgestrel intra-uterine system.
Medications that can cause abnormal uterine bleeding:
Anticoagulants
Acetylsalicylic acid
Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants)
Hormone replacement therapy
Tamoxifen
Phenothiazines
Corticosteroids
Thyroxine
Contraceptives
Herbs: ginseng, ginkgo, soy products

Futher investigation based on clinical suspicion
SYSTEMIC CAUSES INITIAL INVESTIGATIONS
Thyroid disease (hyperthyroidism or hypothyroidism) Sensitive thryroid-stimulating hormone test
Polycystic ovary syndrome
Free testosterone, DHEAS, luteinizing hormone:
follicle-stimulating hormone>3:1
Coagulopathies, leukemia, thrombocytopenia
Complete blood count, INR, partial
thromboplastin time, bleeding time
Pituitary adenoma or hyperprolactinemia Fasting prolactin
Hypothalamic suppression due to stress, weight loss,
excessive exercise, eating disorder Measure weight
SYSTEMIC CAUSES INITIAL INVESTIGATIONS
Hepatic disease Liver function tests, INR
Renal disease Creatinine
Adrenal hyperplasia DHEAS, free testosterone
Cushing disease
24-hour urine free cortisol, overnight
dexamethasone suppression test

25. After hx and examination, you think she needs endometrial sampling,
her pap smear was normal 3months ago.
- Introduce & greeting, clarify identity
- Ask patients understanding of procedure
- Informs :
Why :
-to help in making accurate diagnosis ( to find the cause of abnormal menstral bleeding-heavy,
prolonged & irregular. Bleeding after menopause, bleeding on OCP, thickened uterine lining seen on
ultrasound, infertility )
- give appropriate treatment
- may worsen your condition if delay in diagnosis
What is endo sampling/biopsy :
-is a technique of removing a small piece of tissue from the lining of the uterus (we called it
endometrium ) for analyzed under a microscope.
How it done :
Do in the clinic( out-patient), no need anesthesia
Wear comfortable clothes, come 30min early. No need fasting.
- Lie on your back with feet supported by foot rests
- Doctor will gently insert an instrument called speculum into your vagina to hold it open so
that your cervix can be viewed.
- The cervix is cleaned with a special liquid
- LA will be applied to the cervix
- The cervix may then be gently grasped with an instrument to hold the uterus steady &
another instrument may be needed to gently stretch the cervical opening if there is
tightness
- A metal or plastic tubular instrument is gently passed through the cervix into the uterus to
collect the tissue sample. The tissue will be send to lab for examination.
- Pre-procedure : do not douche, do not apply any cream or medicine in the vagina, makesure
not pregnant & inform if on any medication such as warfarin, aspirin , clopidogrel.
- Post- procedure : pain & discomfort

Rish of procedure :
-infection, perforating the uterus, tearing the cervix( rare), prolonged bleeding, slight spotting &
mild cramping for few days

Ask for consent & show respect for pts automony in making decision.

26. 19 yr old girl came with dysmenorrhoea, please proceed.
-introduce & greeting
-clarify what she means by dysmenorrhea,
since when ( primary dysmenorrhea within 3 years of menarche , secondary dysmenorrhea- a/w
pathology & later in relation to menarche ),
onset ( primary- during menses & lasting for 2-4 days, secondary- prior menses),
duration,
severity ( affect her daily life of activity )
associated symptoms- menorrhagia& dyspareunia {? Secondary }, s/s of anaemia, [primary
:malaise, fatigue, irritability, dizziness, headache, nausea, vomiting, backache, diarrhea],
LOA,LOW{secondary} , PV discharge, fever{PID}
relieving factor rest, pain killer?
-O&G history
Age of menarche
LMP ( TRO ectopic pregnany if 1st episode )
sexual history ( multiple sexual partner- ? PID )
Contraception( IUCD copper )
Number of pregnancy, history of recurrent abortion, D&C ( Asherman syndrome)
-family history of similar problem ( primary )
-surgical history (TRO adhesion colic - multiple op)
-drug history (analgesic dependent, side effect of NSAID )
-social history (stress with study/ work), trauma?
Psychological implication of the problem-
Absence from work/ school, relationship with family
diagnosis :
primary dysmenorrhea : no obvious cause ( due to increased amount of
prostaglandin), common in young adolescent, family history), symtoms usually improve
with age & childbirth
PE : NAD
secondary dysmenorrhea : uterine growth ( adenomyosis, endo polyps, fibroid
Endometriosis, Uterine abnormalities, Cervical stenosis
IUCD ( copper ), PID
PE: abdominal palpation & bimanual examination may reveal presence of enlarged uterus or
adnexal masses & Rectovaginal examination may reveal tenderness.

Ix : U/S of pelvis, Diagnostic Lap, Diagnostic hysteroscopy or saline infusion sonohysterography, MRI
pelvis
Treatment for primary:
Pharmaco : 1st line NSAID ( mefenamic acid,Ibuprofen, naproxen)- 80% relief or COX-2,PCM
2nd line COCs ( need contraception at the same time ), IUCD ( mirena)
Surgical : Laparoscopy, presacral neurectomy, lap uterine nerve ablation, total hysterectomy when
no other cause is found & all other treatment are ineffective.
Treatment for secondary : look for the cause & treat accordingly ( exp: laparoscopy for diagnostic &
operative , hysterectomy+/- BSO )
Non-pahrmaco : Encourage aerobic exercise or can use topical heat treatment, stress management,
stop smoling, alcohol, avoid exposure to cold.

27. A coupe came for unable to have kid for 3yrs, please proceed.
-greeting & introduce
-reason for visiting

counseling & investigation is depends on patients/ couple is age :
1st : assess for any factors that may optimize or contraindicate the planned pregnancy
2nd : possible underlying causes of infertility
3rd : impact of infertility on the individual & relationship.

History taking
-duration of marriage ? [ASRM 1 year, RCOG/NICE-2 years of unprotected sexual intercourse] [
84% of couple will conceive within 1 yr of unprotected sex, 50% in the 2nd yr]
-pyschosomatic & psychosexual problems : relationship , stress @ work, family stress,
Coitus frequency, use of lubricants, adequate penetration with intercourse & ejaculation &
expectation for the future.

-women :
-LMP, menstrual pattern, dysmenorrhea, menorrhagia- [ TRO uterine growth], amenorrhea -[
primary amenorrhea ? xxy testicular ferminization, imperforate hymen, transverse virginal septum,
cervical or virginal agenesis],
-past medical illness : DM, obesity, thyroid disease, adrenal d/o, SOL- prolactinoma, PID/STD
-past surgery history: hx of recurrent abortion -D&C, hysterectomy etc..
-drug hx : radiation , cytotoxic, chemicals
-diet hx : malnutrition , anorexia nervosa
-social hx : stress @ work, excessive sport , alcohol, smoking
-family hx of infertility
-men:
-past medical illness: mumps, systemic illness, STD
-surgery hx : op for hernia, varicocoele or undescended testis
-drug hx : chemo or radiotherapy, steroid
-social hx : occupation & lifestyle( heat, pesticide, herbicide ), ejection or erection problem,
smoking, alcohol
-family hx of infertility

Tell patient/ couple we are going to examine & do few investigations to find out the course of
infertility. Give preconception counseling while waiting for the test result.
-Preconceptual counseling :
Discussion include : -mother :spontaneous abortion, LSCS, DM. baby : aneuploidy in
advancing age couple.
Encourage sexual intercourse every 2-3 days
Advice :
-women : no excessive alcohol consumption & stop smoking ( risk of fetal harm & reduce
fertility). Encourage exercise : BMI 19-29 is optimal.
Encourage take dietary supplementation with folic acid before conception & up to 3/12
gestation to reduces the risk of having a baby with neural tube defects.
-men : excessive alcohol intake can reduce the quality of semen & smoking is associated with
reduced sperm parameter. Avoid occupational hazards, usage of long term prescription
medication.
P/E :
-women :
BMI ( obesity), secondary sexual characteristic, androgen excess, galactorrhoea, acanthosis
nigricans, pelvic mass, speculum & bimanual examination
-Husband :
Hernias, abnormality of testicular size, varicocoele, urethral orifice, epididymis, vas deferens
Investigation :
- Women : Day 2 FSH /LH, D21 progesterone,oetradiol, testosterone, screen for chlamydia
before undergoing instrumentation, rubella status, ,thyroid function test ( amenorrhoea),
sr.prolactin( hyperprolactinaemia ), 17 hydroxyprogesterone( only in clinical & biochemical evidence
of hyperandrogenism- congenital adrenal hyperplasia), TVS for the assessment of uterine cavity
- Men : semen analysis, FSH, LH, testosterone

If mens semen analysis & womens blood test are normal then proceed with hysterosalpingography
for tubal assessment. KIV laparoscopy & dye hydrotubation if the woman has comorbidities( PID,
previous ectopic pregnancy or endometriosis )

Refer to tertiary if :
Women age < 30 yrs who are unable to conceive after regular unprotected intercourse for 2
years without any known reproductive pathology
Women aged > 30 who are unable to conceive after regular unprotected intercourse for a
year without any known reproductive pathology
Patients with a known history of reproductive pathology. Male with hx of urogenital surgery
etc..
Severe abnormality of the initial sperm sample
Retrograde ejaculation & anejaculation

28. You think the husband needs seminal fluid analysis, counsel him.
Assuming both husband and wife there
Introduce self to couple,
Ask husband if he wants privacy, or be alone during this consultation
How are you
Do you understand why you are here?
Infertility is a shared problem, 33% female factor, 33% male factor, 33% unknown
Male factor can easily be determined by one test, seminal fluid analysis.
Can see quality of sperm and completely rule out male factor if normal, because female factor got
multiple tests.
What is seen in SFA
Sperm count
Motility
Morphology
Volume
Fructose level
PH
Liquefaction (viscosity)
Are you comfortable with this this, respect your decision but I highly recommend this test for the
reasons above.
How is it done?
Preparation
-No sexual activity (avoid ejaculation) 3 days prior to test,
Ensure sperm count will be highest
Do not avoid sexual activity for more than 1 to 2 weeks before this test, because a long period of
sexual inactivity can result in less active sperm

-Avoid alcohol, smoking, recreational drugs 3 days prior (can reduce sperm count)

Methods- masturbation, coitus interrupts, special condom
-Preferably masturbation (most common) in a designated room in this clinic/ hospital
-privacy during procedure reassured
-Because sample must be sent to the laboratory 15-30 mins after ejaculation
- Into sterile container, will be provided
-not to use any lubricant with spermicidal agent

After obtaining sample
Send to lab ASAP (15 to 30 mins)
Keep sample in body temperature
Reassure again on privacy, etc

Inform if sample might need to be repeated if insufficient, unsatisfactory
TCA patient to review results

29. After 4 months of treatment, finally the wife pregnant but she
presented with severe vomiting at POA of 6weeks, please proceed.
Introduce self to couple
Ask lady how are you?
History of vomiting
How many episodes
Amount
Able to take orally
Appetite
Fatigue
Dizziness
Weakness
Urine output
bleeding
LOC
Abdominal pain (rule out acute abdomen)
Past medical history (hyperthyroid)
Drug history, allergy
Nausea and vomiting occurs in 50-90% of pregnancies.
The nausea and vomiting associated with pregnancy usually begins by 9-10 weeks of gestation,
peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks.
In 1-10% of pregnancies, symptoms may continue beyond 20-22 weeks

Meaning of Hyperemesis
More severe form of nausea and vomiting in pregnancy with excessive nausea, vomiting with
ketosis, weight loss (>5%)
Can cause volume depletion, electrolytes and acid imbalance
Due to beta hCG hormone (released by corpus luteum)
Resolves after 12 weeks of gastation
What needs to be done?
Examination to determine level of dehydration
Vital signs
Volume status (skin turgor, mucous membrane, mental status)
Thyroid evaluation (high hCG levels that cause transient hyperthyroidism)
Abdomen, cardiac, neuro

Lab test
Urine and serem ketone
Thairoid fuction
Haematocrit
Beta hcg
Imaging
Ultrasound TRO twin and molar
Management
Initial should be conservative, to admit or hydrate if cannot take orally
Diet recommendations
Initial suggestions for dietary modification in patients with nausea and vomiting associated with
pregnancy include the following:
Eat when hungry, regardless of normal meal times.
Eat frequent small meals.
Avoid fatty and spicy foods and emetogenic foods or smells. Increase intake of bland or dry
foods.
Eliminate pills with iron.
High protein snacks are helpful.
Crackers in the morning may be helpful.
Increase intake of carbonated beverages.
Other suggested foods include herbal teas containing peppermint or ginger, other ginger-
containing beverages, broth, crackers, unbuttered toast, gelatin, or frozen desserts.
Preconception use of prenatal vitamins may decrease nausea and vomiting associated with
pregnancy.

Medications
Vitamins (eg, pyridoxine)
Herbal medications (eg, ginger)
Antiemetics (eg, doxylamine-pyridoxine, prochlorperazine, promethazine, chlorpromazine,
trimethobenzamide, metoclopramide, ondansetron)
corticosteroids (eg, methylprednisolone)
Antihistamines (eg, meclizine, diphenhydramine)

30. 34 yr old primed came to review MGTT, FBS: 6.5, 2HPP: 8.8. please
proceed.
Introduce self,
Congratulate her on her pregnancy
Ask gestational age
Ask if she knows why she came
Came to review her diabetic test results,
Need to inform that you have diabetes in pregnancy, aka Gastational diabetes (GDM)
---pause
Explain test said 6.6/8.8,
Normal value less than 6.1/7.8
Yours is actually in IFG and IGT
But in pregnancy it is considered GDM
---any questions
Few components need to explain:
1) Risks in pregnancy
Recurrent miscarriages
IUD later in pregnancy
Big baby, >4kg and if big, risk of birth injury, eg. Shoulder dystocia, extended tear
However all these risks will reduce with good sugar control
2) Dietician referral for diabetic diet
3) Monitoring BSP
Blood sugar profile to be done 4 times a day, first taken this week
Timings 730am (fasting), 1130am (post breakfast), 530pm(pre-dinner), 10pm (post dinner)
Normal value between 4-6.5,
If within normal range, BSP monthly till delivery
If higher than normal, than need to start insulin and BSP 2 weekly till delivery
4) Delivery
If not on insulin, to deliver at term
If on insulin, to deliver at 38 weeks because high risk of IUD

Indication for MGTT:
Age > 25
First degree relative DM
Prev history of GDM
H/o big baby (4kg above)
BMI > 27
Bad obs history
Glycosuria at first perinatal visit
Current obs problem; PIH, steroids, polyhydroamnios, hypertention
31. 43yr old lady came for opinion regarding the risk of getting abnormal
child if she pregnant at this age, she just married 2 months ago.
First of all, it may take longer for her to get pregnant (limited number of eggs in women, and as the
age increases, she may ovulate less and quality of egg may decrease)

Risk in her pregnancy (aged 35 & above):
- Gestational diabetes mellitus (which also increase the risk of fetal anomalies)
- Hypertension disease in pregnancy
- Congenital anomalies risk is higher
- Risk of miscarriage is higher (possibly due to higher rate of chromosomal abnormalities)
- Higher chances of LSCS (due to comorbids / labour problem)
- Preterm delivery
- Low birth weight
- Placenta praevia

For example, risk of trisomy 21 (Down syndrome) increase with age:
25 years of age has a risk of 1 in 1,250
30 years of age has a risk of 1 in 1,000
35 years of age has a risk of 1 in 400

Reminder: risk of fetal anomalies is present even in normal young population

Reassurance: however it is not impossible to have a normal, healthy pregnancy

Steps that can be taken:
1) Prenatal care (optimize health issues, reduce weight etc)
2) Start folic acid early, ex 3 months before conception
3) If pregnant, regular and more frequent antenatal check up
4) Antenatal testing
- Chorionic villous sampling (11 wk to 13wk + 6)
- Amniocentesis (15 week onwards)
- Can take sample for karyotyping
- Procedural risks (infection, risk of miscarriage add 1% to normal rate of miscarriage)
- Option to terminate the pregnancy/ at least to be psychologically prepared during delivery

Also reminds her paternal age also affect fertility and increase chance of abnormal baby

32. You received call from OT, bb of pre-ecclampsia mother POA 35weeks
just delivered, ONG ppl want you to standby. Proceed with resus of
newborn.
Recommended scheme:

33. Peads ward ppl called, they are referring a d3 of life bb for jaundice,
please proceed.
Possible causes:
1) Physiological jaundice
2) Breast milk jaundice
3) Infection (such as UTI)
4) Hemolysis (G6PD deficiency/ABO incompatibility)
5) Bruising / cephalohematoma
6) Polycythaemia
7) Crigler-Najjar syndrome (rare)
Assess the risk factors for jaundice:
1) Risk of perinatal infection such as chorioamnionitis/ maternal pyrexia/ infectious status of
mother
2) Maternal blood group & rhesus status
3) Cord TSH & G6PD
4) Family history of haemolytic disease such as spherocytosis
5) Mode of delivery (cephalohematoma with vacuum delivery)
Assessment of baby:
1) Clinical estimation of jaundice to decide urgency of management (jaundice to face/chest
abdomen/feet)
2) Sign & symptoms of infection : fever, poor feeding, irritability, vomiting
3) Type of feeding (breast feeding vs formula) & adequacy of feeding
4) Colour of stool (pale stool indicates conjugated hperbilirubinaemia biliary atresia)
5) Hepatosplenomegaly (usually present in rhesus haemolytic disease, absent in ABO
incompatibility)
6) Cephalohematoma

Initial investigation serum bilirubin level
Other investigations guided by clinical suspicion:
FBC, reticulocyte count, peripheral blood film, LFT with conjugated/unconjugated bilirubin, blood
grouping, TFT, Coombs test, urine FEME & urine C+S
Treatment:
Adequate feeding
Phototherapy vs exchange transfusion depending on SB level

34. Mother bring a 5 yr old boy to you, she said his penis foreskin unable
to cover back the glands penis after she forcefully retract the foreskin
during bathing her son. Please proceed, the boy is crying in pain.
Paraphimosis
Occurs when a tight prepuce is retracted and then is unable to be replaced as the glans swells. This is
a urological emergency. Always check there is no encircling foreign body constricting venous return,
such as a ring, rubber band or hair.
Risk factors
A tight prepuce causes swelling when it is retracted. This may occur after failing to pull the
foreskin forward to its natural position after cleaning or catheterisation.
Scarring of the prepuce after repeated forcible retraction in an attempt to 'cure' a
physiological phimosis.
Vigorous sexual activity.
Chronic balanoposthitis (typically in diabetic patients).
Penile piercing can lead to paraphimosis but the most common cause is urinary
catheterisation when after inserting the catheter there is failure to replace the foreskin over
glans after the procedure.

Genitourinary History and Examination (Male)
Presentation
There is oedema around the constricting band that is usually the prepuce.
There may be pain on erection.
Infants may present just with irritability.
A carer may discover the condition incidentally in a debilitated patient.
In later stages, the glans may develop a blue or black colour due to necrosis.
Management
Gentle compression with a saline-soaked swab followed by reduction of the prepuce over
the glans is usually successful.
Gradual manual reduction of the prepuce over the glans is done by placing both index
fingers on the dorsal border of the penis and thumbs on the glans. The glans is pushed back
while the index fingers pull the prepuce back over the glans.
This technique can be facilitated by trying to achieve reduction of swelling first. Ice may be
applied. Manual compression is achieved by asking the patient to squeeze the glans for
anything from 5 to 30 minutes. Osmotic reduction involves application of a swab soaked in
50% dextrose to the swollen area for an hour.
If simple methods fail then refer urgently to a urologist.
Alternatives include multiple punctures in the oedematous foreskin or injection of
hyaluronidase prior to compression reduction. General anaesthesia may be required.
If local anaesthetic is required it must not contain adrenaline.
Dorsal incision is occasionally required.
There is no consensus regarding circumcision after paraphimosis. Some authorities maintain
that since the foreskin continues to develop normally after reduction this should not be
necessary. However, it may be advocated in certain circumstances, eg the presence of
chronic balanoposthitis.

35. A 4 yr old child presented with recurrent fever with UFEME showed
positive nitrate. You noted he has phimosis. Please counsel the father.
Phimosis
- Almost all boys have a non-retractile foreskin at birth - physiological phimosis
- not a problem unless it causes difficulties such as urinary obstruction, haematuria or local
pain.
- The foreskin does not retract before the age of 2 years
- The majority of boys will have a retractile foreskin by 10 years of age and 95% by 16-17 years
of age.
- The process of retractility is spontaneous and does not require manipulation.
- Pathological phimosis - results from episodes of foreskin infection (balanoposthitis) a
vicious cycle of repeated attacks of infection lead to scarring which results in further
infections.

Presentation
History
Physiological phimosis:
- parents concern: foreskin may not yet be retracting, notice the naturally-occurring adhesions,
anxious about ballooning during micturition
- Problems relating to physiological phimosis may include recurrent balanoposthitis and recurrent
urinary tract infections.

Pathological phimosis:
- may present as painful erections, haematuria, recurrent urinary tract infections, preputial pain and
weak urinary stream.
Examination
- may be swelling redness and tenderness of the prepuce with purulent discharge
- adhesions may be seen between the inner surface of the prepuce and the glans or the frenulum.
- The frenulum itself may be shortened and retraction of the foreskin may lead to ventral distortion
of the glans.
- Physiological phimosis: meatus will appear healthy and unscarred.
- Pathological phimosis: the meatus may appear scarred, with a fibrous white ring forming around
the preputial orifice.
Investigations
A swab may be taken to confirm the nature of infection but attention is towards physical cleaning
rather than antibiotics.
Management
- find out why the patient has presented at this time and what problems the condition is
causing.
- Both patient and parental expectations should be explored and the options explained.
Non-retractile foreskin and/or ballooning during micturition in a child under two, an
expectant approach should be taken in case this is physiological phimosis which will resolve
in time.
Avoid forcible retraction of a congenital phimosis as this can result in scar formation and an
acquired phimosis.
Personal hygiene: advise cleaning under a retractable foreskin and always reduce it to cover
the glans after cleaning.
Topical steroid application to the preputial ring to treat 'phimosis' has reported success rates
between 33-95%.
Phimosis persisting after the age of two years may be considered for further treatment,
particularly if recurrent infections of the foreskin (balanoposthitis) or urinary tract infections
are occurring. The options are plastic surgery or circumcision.

36. Upon discharging a bb d2 of life, mother noted bb has a small lump at
right inguinal region, size increases while bb crying or straining. Please
proceed.
Inguinal hernia
Epidemiology
Male:female ratio is 8:1.
They affect 1-3% of young children.

Risk factors
In infants: prematurity, male sex.

Presentation
An impulse (increase in swelling) may be palpable in crying infant.
It may not be possible to see the hernia if it is reduced.
If a lump is present, it may be reducible

*Congenital inguinal hernias are usually detected at birth, and all need urgent outpatient referral for
surgical repair.
At first appearance, a hernia is usually easily reducible when the patient reclines. However, it
may require manual replacement if large.
With time, the hernia enlarges and becomes harder to replace, due to fibrous adhesions
forming.
When it can no longer be reduced, it is irreducible or incarcerated. This can occur at any
time, as can strangulation. This is when visceral contents of the hernia become twisted or
entrapped by the narrow opening. This compromises the blood supply, causing swelling and
eventually infarction. Strangulation usually leads to bowel obstruction.

There are two types of inguinal hernia:
Indirect: a protrusion through the internal inguinal ring passes along the inguinal canal
through the abdominal wall, running laterally to the inferior epigastric vessels. This is the
more common form accounting for 80% of inguinal hernias, especially in children. It is
associated with failure of the inguinal canal to close properly after passage of the testis in
utero or during the neonatal period.
Direct: the hernia protrudes directly through a weakness in the posterior wall of the inguinal
canal, running medially to the inferior epigastric vessels. It is more common in the elderly
and rare in children.

Assessment
Examine the patient both standing and lying and ask them to cough or strain.
Insert a finger through the top of the scrotum into the external inguinal ring and palpate for
a lump when coughing - cough impulse.
Sliding hernias are probable with large scrotal hernias.

Differential diagnosis
Femoral hernia: this is seen in various forms, at simplest as a small swelling in the top of the
inside of the thigh. Alternatively, it may be deflected to appear higher as an inguinal hernia.
It is either irreducible or reduces only slowly with pressure.
Hydrocele (when differentiating from an inguinoscrotal hernia, note that it is possible to get
above a hydrocele on examination).
Spermatic cord hydrocele.
Lymph node swelling.
Abscess.
Saphena varix.
Varicocele.
Bleeding.
Undescended testis.

Investigations
Ultrasound is the less invasive method, if there is doubt.

Management
Children
The incidence of incarcerated or strangulated hernias in paediatric patients is 10-20%. 50% of these
occur in infants aged younger than 6 months:
Paediatric surgeons will repair soon after diagnosis, regardless of age or weight, in healthy
full-term infant boys with asymptomatic reducible inguinal hernias. Inguinal hernias in
premature infants are usually repaired prior to discharge from the neonatal intensive care
unit (NICU). However, this practice is changing, as infants are now being discharged home at
much lower weights. Some surgeons prefer to postpone the surgery in these very small
babies for 1-2 months to allow further growth.
Herniotomy is all that is required with ligation and excision of the patent processus vaginalis.

Complications
Recurrence: 1.0% - most happening within five years of operation. Recurrence rate
increases:
o In children aged younger than 1 year
o After incarcerations
o In those with ongoing increased intra-abdominal pressure
o Where there is growth failure
o With prematurity
o Where there are chronic respiratory problems
o In girls with sliding hernias
o Infarcted testis or ovary with atrophy.
Wound infection.
Bladder injury.
Intestinal injury.
A hydrocele from fluid accumulation in the distal sac usually resolves spontaneously but
sometimes requires aspiration.

Prognosis
This is generally very good, depending on comorbidity.

Hydrocele
An abnormal collection of fluid within the remnants of the processus vaginalis:
Simple hydrocele:
Accumulation of fluid within the tunica vaginalis.
Affects 1-2% of male neonates. A congenital, simple hydrocele usually disappears within the
first 1-2 years of life.
Causes in older boys and men include trauma, epididymo-orchitis, testicular torsion, hernia,
varicocele, and testicular tumour.
Hydroceles in older boys and men may also be due to generalised oedema, such as
nephrotic syndrome or heart failure.
Communicating hydrocele:
Persistence of the processus vaginalis allows peritoneal fluid to communicate freely with the
scrotal portion of the processus.
They are congenital but may first present in older boys and men as a result of increased
intra-abdominal pressure, continuous peritoneal dialysis or fluid overload.
Hydrocele of the cord:
The processus vaginalis closes segmentally, trapping fluid within the spermatic cord.

*In children, most hydroceles are the communicating type. Non-communicating hydroceles are
caused by excessive fluid production within the tunica vaginalis.

Presentation
Scrotal enlargement with a non-tender, cystic swelling.
Pain is not a feature unless the hydrocele is infected or if there is pain from an underlying
cause.
The testis is usually palpable but may be difficult to palpate if the hydrocele is large.
A hydrocele lies anterior to and below the testis and will transilluminate. Transillumination is
not diagnostic and does not rule out a more urgent scrotal problem.

Differential diagnosis
Differentiating acute scrotal problem such as testicular torsion or strangulated hernia is very
important.

Investigations
Investigations are not required for simple hydroceles but are essential if there is any doubt in the
diagnosis or any suggestion of an underlying cause. Failure to clearly delineate the testis, tenderness
on palpation or internal shadows on transillumination are all indications for further investigation:
Ultrasound can help to determine if any underlying pathology is present. Spermatoceles can
be clearly distinguished.
Duplex sonography may provide information about testicular blood flow when a hydrocele
may be associated with chronic torsion of the testis.
Diagnostic aspirations should be avoided, as they may lead to the spread of malignant cells.
Serum alpha-fetoprotein and human chorionic gonadotrophin levels help to exclude
malignant teratomas or other germ cell tumours.

Management
Many hydroceles in infancy resolve before the age of 2 years and so observation and non-
intervention are usually appropriate for hydroceles in infants. Early surgery in this age group
is indicated if there is suspicion of an associated inguinal hernia or underlying testicular
pathology.
Surgical removal

Complications
Infection of a hydrocele may occur but is uncommon. Complications of operations for hydroceles
include:
Wound infection.
Infertility which may occur with bilateral injury to the vas deferens.
Testicular atrophy which may occur due to injury to the testicular blood supply.
Haematoma.
Temporary or permanent ilio-inguinal or genitofemoral nerve injury due to entrapment or
division during inguinal approaches.
Secondary cryptorchidism due to excessive scar formation.
Recurrence of the hydrocele - usually reactive and resolves within several months.

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