Liza: Dr, I have questions. Is cul de sac same as pouch of Douglas ? And to examine the fluid in that space, we shoud do PR Or bimanual exam ?
Dr Shaiful Ehsan: POD = cul de sac.... Bimanual for adnexal mass....
To examine the fluid....
Clinical = shifting dulness = ascites....
PR also can detect bogginess = fullness at POD...
Friday, 6 November 2015
Vaginal candidiasis
Abdullah Bee: Salam dr, if a non pregnant lady comes with a complain of vaginal pain assoc with whitish dischge n itchiness,,is it most likely to be v.candidiasis?
Im asking this because to know whether v.candidiasis is also common for non pregnen lady
Tq dr
Dr Shaiful Ehsan: Waalaikumsalam....
Its common for woman to have vaginal discharges....
But what becomes pathological if it changes in color, foul smelly, increasing in amount & worsening itchiness...
So if it is pathological....u have to think of vaginitis....
There are multiple aetiological of vaginitis....
Not only candidiasis...
Candidiasis are common in pregnant lady, diabetic, poor hygiene, immunocompromised....
Normal profile without risk factor not common to have vaginal candidiasis...
Typical history of vaginal candidiasis is thick whitish discharges associated with itchiness....
Im asking this because to know whether v.candidiasis is also common for non pregnen lady
Tq dr
Dr Shaiful Ehsan: Waalaikumsalam....
Its common for woman to have vaginal discharges....
But what becomes pathological if it changes in color, foul smelly, increasing in amount & worsening itchiness...
So if it is pathological....u have to think of vaginitis....
There are multiple aetiological of vaginitis....
Not only candidiasis...
Candidiasis are common in pregnant lady, diabetic, poor hygiene, immunocompromised....
Normal profile without risk factor not common to have vaginal candidiasis...
Typical history of vaginal candidiasis is thick whitish discharges associated with itchiness....
IUGR & SGA
Abd Halim: Dr, correct me if im wrong here.
As of lately i noticed many of many collegues can't grasp the topic of FGR.
This is my summary of it.
FGR is the prevention of the fetus to grow to its maximum potential.
It can come in 2 forms. Either IUGR (Intrauterine Growth Restriction) or SGA (Small for Gestational Age).
We can differentiate IUGR from SGA based on their pattern on the growth chart & the process behind them.
In growth chart (fetal weight is used as parameter), fetuses with IUGR will have stunted growth.
I.e: The graph plateaus off. It becomes stagnant after a period of growth.
SGAs still progressively grow, but the graph will be below the 3rd centile.
(Both IUGR & SGA graph will be below the 3rd centile. What differentiates them is the pattern)
All IUGRs are SGAs, but not all SGAs are IUGRs.
Dr Shaiful Ehsan: Dear Halim, some information are corrects....some are not... What is ur reference of SGA & IUGR below 3rd centile
Safira Fyra: From ten tcers, it said some FGR fetuses may not actually be SGA..but nevertheless will hv failed to fulfill their growth potential..So tak semua fgr is sga la kan dr?
Dr Shaiful Ehsan: Yupp....👍🏻👍🏻Anyone would like to give definition of IUGR and SGA?
Safira Fyra: FGR = failure of fetus to achieve its genetic growth potential
SGA = weight of the fetus <10th centile for its gestation
Dr Shaiful Ehsan: Yupp...almost correct...I need more specific answer for iugr...
Liza: Iugr : fetus growth < 10th percentile
Cemak Asma: Rasa mcm sga fetal growth <10th percentile.. Iugr fetal growth between 50th and 10th percentile.. Correct me if i'm wrong
Azyati: Correct me if i'm wrong dr.. Iugr is when growth chart crossing less than 3 centile with oligo. Sga is when EFW + parameter less than 10th centile for that gestational age
Kak Zaim: Dr had mentioned iugr in previous cp session.. Xingat sangat tp dr mcm ada sebut its crosses 2 centiles with or without oligo.. Huhu sorry dr kalau salah
Dr Shaiful Ehsan: Okeylah....nasib baik ada yg masih ingt.... Yupp
SGA is when the fetal parameters & efwt is less than 10th centile for the gestational age....
IUGR when the parameters on plot chart crossing 2 major centiles, usually with presence of oligohydramnios.....
Dr Shaiful Ehsan: HOMEWORK: definition of oligohydramnios....
****ni homework lama ni....xde org reveal answer yet....
Cemak Asma: Oligohydramnios: amniotic fluid index <5th centile for gestation on ultrasound estimation. Tp selalunya amik masa 3rd trimester because afi alters throughout gestation
Dr Shaiful Ehsan: Asma 👍👍👍
Dr Shaiful Ehsan: Oligohyramnios is afi less than 5th centile for respective gestational age....and deepest pole less than 3cm for twin pregnancy...
As of lately i noticed many of many collegues can't grasp the topic of FGR.
This is my summary of it.
FGR is the prevention of the fetus to grow to its maximum potential.
It can come in 2 forms. Either IUGR (Intrauterine Growth Restriction) or SGA (Small for Gestational Age).
We can differentiate IUGR from SGA based on their pattern on the growth chart & the process behind them.
In growth chart (fetal weight is used as parameter), fetuses with IUGR will have stunted growth.
I.e: The graph plateaus off. It becomes stagnant after a period of growth.
SGAs still progressively grow, but the graph will be below the 3rd centile.
(Both IUGR & SGA graph will be below the 3rd centile. What differentiates them is the pattern)
All IUGRs are SGAs, but not all SGAs are IUGRs.
Dr Shaiful Ehsan: Dear Halim, some information are corrects....some are not... What is ur reference of SGA & IUGR below 3rd centile
Safira Fyra: From ten tcers, it said some FGR fetuses may not actually be SGA..but nevertheless will hv failed to fulfill their growth potential..So tak semua fgr is sga la kan dr?
Dr Shaiful Ehsan: Yupp....👍🏻👍🏻Anyone would like to give definition of IUGR and SGA?
Safira Fyra: FGR = failure of fetus to achieve its genetic growth potential
SGA = weight of the fetus <10th centile for its gestation
Dr Shaiful Ehsan: Yupp...almost correct...I need more specific answer for iugr...
Liza: Iugr : fetus growth < 10th percentile
Cemak Asma: Rasa mcm sga fetal growth <10th percentile.. Iugr fetal growth between 50th and 10th percentile.. Correct me if i'm wrong
Azyati: Correct me if i'm wrong dr.. Iugr is when growth chart crossing less than 3 centile with oligo. Sga is when EFW + parameter less than 10th centile for that gestational age
Kak Zaim: Dr had mentioned iugr in previous cp session.. Xingat sangat tp dr mcm ada sebut its crosses 2 centiles with or without oligo.. Huhu sorry dr kalau salah
Dr Shaiful Ehsan: Okeylah....nasib baik ada yg masih ingt.... Yupp
SGA is when the fetal parameters & efwt is less than 10th centile for the gestational age....
IUGR when the parameters on plot chart crossing 2 major centiles, usually with presence of oligohydramnios.....
Dr Shaiful Ehsan: HOMEWORK: definition of oligohydramnios....
****ni homework lama ni....xde org reveal answer yet....
Cemak Asma: Oligohydramnios: amniotic fluid index <5th centile for gestation on ultrasound estimation. Tp selalunya amik masa 3rd trimester because afi alters throughout gestation
Dr Shaiful Ehsan: Asma 👍👍👍
Dr Shaiful Ehsan: Oligohyramnios is afi less than 5th centile for respective gestational age....and deepest pole less than 3cm for twin pregnancy...
Bilateral ovarian cyst - tahbso/ hysteroscopy & dd&c
Syamila: Assalamualaikum Dr.I clerk this pt.initially she was electively admitted for tahbso due to bilateral ovarian cyst.however, this morning dr decided to do hysteroscopy and dd&c instead of tahbso in order to rule out any endometrial pathology. so, my questions:
1)how i want to write my chief complaint? is it still EA for tahbso...or...??
2)why dr suddenly change the operation?
Abd Halim: Sbb dalam hx die latest pipelle sampling showed benign endometrial hyperplasia instead of initial findings which were more malignant in nature.
Dr Shaiful Ehsan: Waalaikumsalam syamila...
That is why in Chief complaint i will advice u guys not to mentioned specific procedure or diagnosis in exam.....becoz it will usually changed after our preop rounds on monday & wednesday afternoon with consultants...
U can write ur CC eg like this:
38 yr old, teacher, para 3, electively admitted for further MANAGEMENT of her underlying abdominal mass for the past 1 year associated with dysmenorrhea...
She was apparently well till...bla bla2..
Dr Shaiful Ehsan: Q2: why suddenly...
Becoz usually the plan for operation is made by 1 specialist while we see this case at gynae clinic...with or without consulting the consultant (usually Dr alik / Dato Rozihan)...
During this time, patient might agree for the above operation....
However, we usually benefit our pre-op rounds....in which we will explore further patient understanding and social background profile.....in which some operation need to be change to meet patient's need...
Dr Shaiful Ehsan: Eg, if this patient is postmenopause & alreday completed family....there is NO WRONG of doing tabhso...
However, if this patient is young, you need to explain to patient that with tabhso...she will get PREMATURE menopause....in which she need to take HRT for at least her age till 50....
And she should understand her risk to develop osteoporosis and Cardiovasvular event is higher compared to those without prem menopause....
Dr Shaiful Ehsan: These are among issues we will discuss back with patients at pre op rounds...in which I DO BELIEVE SHOULD BE DISCUSSED EARLIER....
Other reason possible if the workout so far is still not clear enough....i which the mass could not arising from ovary....but actually benign from uterus.....
In which JUMP into TABHSO is totally not appropriate but hysteroscopy and biopsy is more accurate and justifiable before further surgical options can be discussed...
Thank u very much...
Oh ya...other benefits of not mentioning diagnosis and procedure in chief complaint is that:
U can have diffirential doagnosis in discussion
U can have better provisional diagnosis talley with ur patient presentation
You can vomit out ur fantastic principle of management.....rather than being rigid....tq
1)how i want to write my chief complaint? is it still EA for tahbso...or...??
2)why dr suddenly change the operation?
Abd Halim: Sbb dalam hx die latest pipelle sampling showed benign endometrial hyperplasia instead of initial findings which were more malignant in nature.
Dr Shaiful Ehsan: Waalaikumsalam syamila...
That is why in Chief complaint i will advice u guys not to mentioned specific procedure or diagnosis in exam.....becoz it will usually changed after our preop rounds on monday & wednesday afternoon with consultants...
U can write ur CC eg like this:
38 yr old, teacher, para 3, electively admitted for further MANAGEMENT of her underlying abdominal mass for the past 1 year associated with dysmenorrhea...
She was apparently well till...bla bla2..
Dr Shaiful Ehsan: Q2: why suddenly...
Becoz usually the plan for operation is made by 1 specialist while we see this case at gynae clinic...with or without consulting the consultant (usually Dr alik / Dato Rozihan)...
During this time, patient might agree for the above operation....
However, we usually benefit our pre-op rounds....in which we will explore further patient understanding and social background profile.....in which some operation need to be change to meet patient's need...
Dr Shaiful Ehsan: Eg, if this patient is postmenopause & alreday completed family....there is NO WRONG of doing tabhso...
However, if this patient is young, you need to explain to patient that with tabhso...she will get PREMATURE menopause....in which she need to take HRT for at least her age till 50....
And she should understand her risk to develop osteoporosis and Cardiovasvular event is higher compared to those without prem menopause....
Dr Shaiful Ehsan: These are among issues we will discuss back with patients at pre op rounds...in which I DO BELIEVE SHOULD BE DISCUSSED EARLIER....
Other reason possible if the workout so far is still not clear enough....i which the mass could not arising from ovary....but actually benign from uterus.....
In which JUMP into TABHSO is totally not appropriate but hysteroscopy and biopsy is more accurate and justifiable before further surgical options can be discussed...
Thank u very much...
Oh ya...other benefits of not mentioning diagnosis and procedure in chief complaint is that:
U can have diffirential doagnosis in discussion
U can have better provisional diagnosis talley with ur patient presentation
You can vomit out ur fantastic principle of management.....rather than being rigid....tq
Ectopic pregnancy & miscarriage
Cemak Asma: Salam doctor.. Me n my frens have a few questions.
1. How many weeks of gestation can we diagnose a pregnancy as ectopic? Sbb ada setengah patient tu doc suruh tunggu dulu baru confirmkan.
Dr Shaiful Ehsan: Q1: Ectopic pregnancy can be diagnosed as early as clinical suspicion is high....either in early 1st trimester till 3rd trimester....
I did mention to some of u guys that while I in H Keningau we did encounter ectopic pregnancy in ovary not detected early and that time already around 30 - 32 weeks....
If clinical suspicion is high...TVS is good enough to see free fluids and adnexal mass in which u need to do laparosopic surgery to identify and manage...
There is no point of waiting as it will rupture and leads to sepsis & death...
Usually wait is for missed miscarriage for those opt for conservative management....
Or on TVS no suspicious findings were found in which patient most probably had wrong date!!!!
2. How can molar pregnancy lead to preecplampsia? Is it because of the hyperthyroid state?
Dr Shaiful Ehsan: Q2: Molar pregnancy is associated with excessive hormones released from placenta....including anti angiogenic proteins from its trophoblast...
Antiangiogeneses = inadequate blood vessel formation = culprit for PIH and PE...
3. Regarding inevitable miscarriage.. Some books classify complete and incomplete miscarriage under inevitable but some dont.. Yg classify inevitable as it own entity, dy kata on ultrasound we can still see fetal heart activity. But this is not present if complete n incomplete miscarriage.. So kami dah pening 😅 inevitable ni nak letak bawah mana? Huhu
Dr. Shaiful Ehsan:Q3: incomplete or complete miscarriage is an outcome.....
Of any miscarriage either inevitable or missed miscarriage that treat conservatively and passed out...
Complete miscarriage means ET is already thin...no REMAINING POC....
Incomplete there is still remaining POC...
Above statement that u shared is misleading...tq
Cemak Asma: So doctor if inevitable miscarriage, will it still be possible to see fetal heart activity? I dont quite understand this part
Dr Shaiful Ehsan: The golden difference between inevitanle and threatened miscarriage is cervical os opening...
Presence or absence FH is not part of criteria for inevitable miscarriage....
Nevertheless it is more common to have absence FH in inevitable miscarriage...
Yupp...u still can have FH in inevitable miscarriage
Btw...threathened miscarriage MUST HAVE FH...tq
Cemak Asma: Ohh okay doctor.. Thank you
⛄⛄⛄⛄⛄⛄⛄⛄
Adlina: Assalamualaikum Dr. How ruptured fallopian tube due to ectopic pregnancy can cause diarrhea?
Dr Shaiful Ehsan: Waailaikumsalam adlina, ruptured ectopic pregnancy will cause intraperitoneal harmorrhage....blood is irritants in which will induce inflammatory cascade upon contact with bowel or surface...
Eg making contact with diaphgram will cause shoulder tip pain
Making contact with bowel will induce inflammation of the bowel wall, increase peristaltic movement & reduced absorption....= diarrhea
1. How many weeks of gestation can we diagnose a pregnancy as ectopic? Sbb ada setengah patient tu doc suruh tunggu dulu baru confirmkan.
Dr Shaiful Ehsan: Q1: Ectopic pregnancy can be diagnosed as early as clinical suspicion is high....either in early 1st trimester till 3rd trimester....
I did mention to some of u guys that while I in H Keningau we did encounter ectopic pregnancy in ovary not detected early and that time already around 30 - 32 weeks....
If clinical suspicion is high...TVS is good enough to see free fluids and adnexal mass in which u need to do laparosopic surgery to identify and manage...
There is no point of waiting as it will rupture and leads to sepsis & death...
Usually wait is for missed miscarriage for those opt for conservative management....
Or on TVS no suspicious findings were found in which patient most probably had wrong date!!!!
2. How can molar pregnancy lead to preecplampsia? Is it because of the hyperthyroid state?
Dr Shaiful Ehsan: Q2: Molar pregnancy is associated with excessive hormones released from placenta....including anti angiogenic proteins from its trophoblast...
Antiangiogeneses = inadequate blood vessel formation = culprit for PIH and PE...
3. Regarding inevitable miscarriage.. Some books classify complete and incomplete miscarriage under inevitable but some dont.. Yg classify inevitable as it own entity, dy kata on ultrasound we can still see fetal heart activity. But this is not present if complete n incomplete miscarriage.. So kami dah pening 😅 inevitable ni nak letak bawah mana? Huhu
Dr. Shaiful Ehsan:Q3: incomplete or complete miscarriage is an outcome.....
Of any miscarriage either inevitable or missed miscarriage that treat conservatively and passed out...
Complete miscarriage means ET is already thin...no REMAINING POC....
Incomplete there is still remaining POC...
Above statement that u shared is misleading...tq
Cemak Asma: So doctor if inevitable miscarriage, will it still be possible to see fetal heart activity? I dont quite understand this part
Dr Shaiful Ehsan: The golden difference between inevitanle and threatened miscarriage is cervical os opening...
Presence or absence FH is not part of criteria for inevitable miscarriage....
Nevertheless it is more common to have absence FH in inevitable miscarriage...
Yupp...u still can have FH in inevitable miscarriage
Btw...threathened miscarriage MUST HAVE FH...tq
Cemak Asma: Ohh okay doctor.. Thank you
⛄⛄⛄⛄⛄⛄⛄⛄
Adlina: Assalamualaikum Dr. How ruptured fallopian tube due to ectopic pregnancy can cause diarrhea?
Dr Shaiful Ehsan: Waailaikumsalam adlina, ruptured ectopic pregnancy will cause intraperitoneal harmorrhage....blood is irritants in which will induce inflammatory cascade upon contact with bowel or surface...
Eg making contact with diaphgram will cause shoulder tip pain
Making contact with bowel will induce inflammation of the bowel wall, increase peristaltic movement & reduced absorption....= diarrhea
Pprom- cord prolapsed
Izzat Mubarak: Salam Dr Shaiful...
I have a question...why do you have to exclude cord prolapse in PROM?
Is the cord prolapse due to unstable lie?? Or just because it is a possible complication of PROM??
Umair: Kalau tak silap complication of prom. Due tu sudden decrease in pressure.
Cemak Asma: Bila liquor tu leak out, cord akan ikut turun sekali sbb dy ringan
Izzat Mubarak: Thank you umair and asma
Dr Shaiful Ehsan: Waalaikumsalam....becoz in prem...head is not engaged yet....
So there is possibility of cord presentation / footling presentation and so on....
I have a question...why do you have to exclude cord prolapse in PROM?
Is the cord prolapse due to unstable lie?? Or just because it is a possible complication of PROM??
Umair: Kalau tak silap complication of prom. Due tu sudden decrease in pressure.
Cemak Asma: Bila liquor tu leak out, cord akan ikut turun sekali sbb dy ringan
Izzat Mubarak: Thank you umair and asma
Dr Shaiful Ehsan: Waalaikumsalam....becoz in prem...head is not engaged yet....
So there is possibility of cord presentation / footling presentation and so on....
Antibiotic GBS
8)how many dose of antibiotics enough to cover for the baby if the mother is GBS positive?
The mother should have receive >/=4hours of IV penicillin, ampicillin or cefazolin prior to delivery
A) penicillin : 5 million units IV initially, then 2.5-3.0 million units IV every 4 hours until delivery
B) ampicillin : 2 grams IV initially, then 1 gram IV every four hours until delivery (with the exception of women with PPROM who may have received 2 grams IV initially and followed by 1 gram IV every 6h)
C) cefazolin : first dose of 2 grams IV followed by 1 gram IV every 8 hours until delivery
Dr Shaiful Ehsan: For GBS...ampicillin is the drug of choice...before u escalate to cephalosporin...
Adequate dose is considered when mother is covered at least 2 completed doses of ampicillin intrapartum before deliver the baby....
📖📖📖📖📖📖📖📖
[04/11 1:03 pm] Dr Shaiful Ehsan: http://www.mmgazette.com/which-antibiotics-should-i-use-dr-mohd-shaiful-ehsan/
[04/11 1:04 pm] Dr Shaiful Ehsan: Purposely written for my juniors....moga bermanfaat...
The mother should have receive >/=4hours of IV penicillin, ampicillin or cefazolin prior to delivery
A) penicillin : 5 million units IV initially, then 2.5-3.0 million units IV every 4 hours until delivery
B) ampicillin : 2 grams IV initially, then 1 gram IV every four hours until delivery (with the exception of women with PPROM who may have received 2 grams IV initially and followed by 1 gram IV every 6h)
C) cefazolin : first dose of 2 grams IV followed by 1 gram IV every 8 hours until delivery
Dr Shaiful Ehsan: For GBS...ampicillin is the drug of choice...before u escalate to cephalosporin...
Adequate dose is considered when mother is covered at least 2 completed doses of ampicillin intrapartum before deliver the baby....
📖📖📖📖📖📖📖📖
[04/11 1:03 pm] Dr Shaiful Ehsan: http://www.mmgazette.com/which-antibiotics-should-i-use-dr-mohd-shaiful-ehsan/
[04/11 1:04 pm] Dr Shaiful Ehsan: Purposely written for my juniors....moga bermanfaat...
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