Imperforate Hymen

A Pediatric Surgery / O&G Interest

I didn't see the patient myself but when I heard it being presented in the morning prayers, I just had to at least go read the case note.

One of the common causes of primary amenorrhea, usually presenting with cyclical abdominal pain, like dysmenorrhea only without the menses. Easily missed diagnosis although easy to make.

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11yo female child with no menses yet presented with history of progressive abdominal distension for 2 months associated with abdominal and back pain. She has no fever and other constitutional symptoms.

Examination reveals an abdominal mass measuring a 24 week size uterus, which was mobile side to side and could not get below the mass.

Examination of the perineum clinched the diagnosis of imperforate hymen. Before this the differential was ovarian and uterine mass.

TAS shows hematometra and hematocolpos. (Something like below although this image was taken from medscape)


Hymenectomy was done. Surgery was uneventful and patient was discharged well the day after the surgery.

For more:
http://emedicine.medscape.com/article/954252-overview

Polyhydramnios - Spectrums

I've decided to write on interesting cases here. In the future I'll decide if they would be included in the travelogue.

Polyhydramnios - Spectrums

Case 1

22yo Primid @ 26W + 3D

Late booker

Referred for further management of fetal anomaly seen in TA scan and reduced fetal movement.

Patient was aysmptomatic, not in labour. V/S were normal. Per abdomen SFH was 30W size, with difficulty to papate the fetal parts and positive fluid thrill. There were no contractions.

TAS revealed:

- Dilated fetal heart. Still beating.

- Fetal ascites.

- Empty mother's Morrison's pouch.

What are other TAS features to look for?

What is the probable diagnosis?

What are the investigations to be performed in this case?

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Case 2

28yo, G4P3 @ 38W+1D

Antenatal problems: Anemia in pregnancy, AFI normal throughout pregnancy, no GDM, fetal anomaly scan not done.

Came in active phase of labour.

V/S stable

PA: Ut size: 38W, singleton, cephalic, head 5/5 floating, difficult to plapate the fetal parts/

Admitted to labour room for controlled ARM. CTG was reactive prior to admission.

On rupturing the membrane, 1.5 L of liquor was drained with fresh blood stains. CTG worsened showing unprovoked decelerations.

Impression was placenta abruption secondary to ARM.

Posted for EMLSCS.

Intraoperatively uneventful.

Baby boy delivered with BW 2.1kg. Admitted to NICU for TTN. Later discovered to have tracheoesophageal fistula, imperforated anus. Planned for thoracotomy, TOF repair and colostomy my the peds surgery team.

Mother was well post-op.

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Maybe I'll write a bit on polyhydramnios when I'm a bit in the mood. I find both cases interesting. There was another with hydrops fetalis but I didn't note the case.

Other cases of polyhydramnios I'm on the lookout for are:

- diabetic causes

- Twin-twin transfusion

- Other fetal anomalies (ie. Spinal disorders due to problems swallowing)

The Backbone of the Wards - Nurses

Hada request from a friend to write about nurses in Sabah (she's a nursing student) and compare them to Peninsular Malaysia nurses. She hears them grudgingly back talk about doctors almost everyday and would like to hear from me if there's any difference.

I think its human nature to back talk whether they mean it or realize it. I'm not encouraging it but just acknowledging its existence. Yes it exist here. Not just among nurses, but among doctors as well. Nurses back talk that arrogant houseman, houseman backtalks that malignant specialist, patients backtalks that nurse. Sometimes you don't hear it, you just sense it. Makes you wonder what people talk or think of you behind you back.

But so far I enjoy working with the nurses here. Its too early to make a general overall conclusion but the nurses I've met are really helpful and most are fun to work with. The labour room staff are a cheerful bunch. They offer food and invite us to Raya at their place. They are the ones who cover our asses and remind us of jobs. They tell us the correct dose for medications and help teach us stitch. The nurses I've met taught me Caesarian section. I have a feeling they'd be able to perform a better C-sec than most new MOs if only they had the license to do so. Most importantly they keep the wards organized and in-check. I believe them to be more professional than most doctors regardless of rank.

Prof Nasa was right. You should treat your nurses you work with with RESPECT. They are not down the food chain. We work together to achieve a common goal. This would be much easier if everyone did not talk behind each others back and be suspicious of each other.

I love my nurses. Make them love you too.

Oh, nurses in KK I've met a lot are pretty and cute too =D

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Malignant Potential

My colleagues sees me being a potential malignant MO.

When compared to IIUM students back home in Kuantan, I less commmonly see UMS students around in the hospital. But when they are around, I do my best to share what I know, tutor style. Apparently, my style of asking questions and waiting for answers got me branded for being potentially malignant.

Back in medical school, most teachings and learning were from making you think. The process occurs better when triggered by a question and those asked finding the answer. Some lecturers ask in a sarcastic or aggressive way. These are the malignant ones. But I still think that these types of teachings are the best. It conditions you. By being scolded, you are more likely to look for the answer in the hope that when next time occurs, you are able to answer and deal with the situation better.

How different it is in the working life? No different. Only that your actions have repercussions. You are still scolded like a little child when you make mistakes. But again, this is another learning process that the mature will take as a lesson instead of as a personal insult. MOs gets the same treatment, specialist gets the same treatment. Always questions first. Makan suap does not suit the medical field. Its how we are trained.

So I don't think becoming malignant that way is that bad. Hell if that will make my apprentices better, than malignant I shall be. But I'll try not to let emotions dictate my actions. Besides, I''m not known to marah orang.

Right? >:D

Sabah Raya, Bah!

Initially we all (UIA team :p) volunteered to work throughout Raya since its too late to buy cheap tickets back anyway. But our beloved Suthagar insisted that we took a few days break saying how he understands how sad it is when someone doesn't come back for Raya.

Thanks alot! We still didnt go back to visit our family but we did had a whole lotta fun!

I planned early with Khairie who's coming back to Renau so that I could follow him and birng my UIA buddies as well. Initially only Nadhir agreed to come along. That Raya night we traveled through mist covered winding mountain roads where the only thing that was visible was the mist and a few centimeters of white line on the road. We could easily run into a car, a wall, or a cliff. But we made it :D

Our Sabah Raya was with Khairie's family. After Raya prayers, we had the usual stuff (I wouldnt know what the usual Raya stuffs are) with me having vege some meat and chicken. and lotsa pineapple tarts! Binge!! Yea and birdwatching in between and the whole time (But I FORGOT MY BINOCS!!!!! which I asked Jazmi whom decided to come along anyway to help bring for me [more on birds in my bird blog]).

After that we went to Kundasang Kinabalu park, took a 200m hike which raised my PR to 140bpm (pancit da panjat ni imagine Gunung Kinabalu!). Saw more birds. Then stopped by a War Memorial on Brits and Aussies whom died after a long march from Sandakan to Renau by the Japs during WW2.

Had KFC. Ayam Renau. And later that evening pampered ourselves at the Poring hotsprings.

That night had a noob game of DoTA I vow never to play again.

Next day we went to Sabah tea garden, where I had omelette du fromage and my first hot lemon tea sedap nak mampous! while watching birds and taking in the pretty scenery. Then took a bath with them fishes serious tak penah buat anything like this! I like had hundreds of fish sucking on my fingers and other body parts (not that).



Then the search for Strawberry farm. Didnt find it but we reached New Zealand with 2 million cows!!!! APA??! 2 JUTA?

On the way to the tip of the world (tip of Borneo sorry for the hyperbolism), stopped by Kota Belud for ayam Kota Belud at KFC.

Then we reached a pretty beach spot. A lotta birds and pictures later we decided to stay the night a chalet. Noice!

Drove down a dark, rocky, dead road to Kudat town. If our car broke down memang were done for. Had dinner at the town and took a different road back and relaxed and sucked in the sea air and went to sleep...

More birds and long rock pool and beach trek to look for even more birds before we had breakfast and went back the long road back to KK...

Bah.

Recommended places:
- Kundasang and Renau just for the spectacular view
- Kinabalu Park
- Poring HotSprings
- Sg Kg Tagal and Fishes
- Sabah Tea Garden
- Tip of Borneo

Brother's visit

My brothers, Shafiq and Iyas, dua2 duo xley blah came to visit me here in KK.

I switched oncalls with Jeriol so Id be free as much as possible on the weekends to spend time with me bros.

The day we came we ate at New york New York, a nice western place I always wanted to try. They serve tall rootbeer floats and steak. Later that night went to Tanjung Aru and had some chicken wings. Bro said it was better than dominoes. I agreed.

Next day took a sudden trip to Manukan island. Man the waters clear! I was so enticed I walked straight in to the sea that I forgot about my BB in my pocket. The end of that BB. Still had fun feeding the fishes. Later we went to a not so nearby crocodile farm. They sell croc meat there! Besides crocs there were some other animals as well. Nice to feed and pet. Even the Bearcat =)

Balik tido.

Later that night tried out a fishfood joint my bro's friend recommended. Sedap gila bab! Serious Ive never enjoyed seafood as much as I did that night. But it was all over the next day and oncall... Sent my bros to the airport. babai...

Hiatus

I have been writing but not on the net cuz had no net connection but my BB which has..... expired.

Now I'll try restart.