TEALE FENNING Medical Education    FAQ   Search   Memberlist   Usergroups   Register   Profile   Log in to check your private messages   Log in  mrcog courses for doctors Causes of Maternal Death Goto page Previous  1, 2, 3, 4  Next          TEALE FENNING Forum Index -> MRCOG Part 2: EMQs - Extended Matching Questions View previous topic :: View next topic   Author Message Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Sat Nov 25, 2006 1:45 pm    Post subject: A 24-year old slim, nulliparous woman who had a vaginal delivery earlier that day complains of shortness of breath when lying down and palpatations. She has some chest pain and eventually coughs up a few flecks of blood. She is fit and well, does not smoke, and had an uneventful pregnancy and labour. On examination her JVP is raised but her blood pressure is normal at 125 / 65 and she is not tachycardic. Cardiac auscultation reveals a 3rd heart sound and a murmur suggestive of mitral regurgitation and there are inspiratory crackles over both lung bases. Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:11 pm    Post subject: answers brainteasers 1 and 2 1. Encephalopathy paints factory - baseline chronic chemical CNS trauma history of febrile illness - super added viral element all the rest is progressively worsening encephalopathy leading to death. this is the acute on chronic encephalopathy picture. 2. Sub arachnoid haemorrhage headache / sudden death with no preceeding symptoms + recent HT + family history = rupture of berry aneurysm subarachnoid haemorrhage death. _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:13 pm    Post subject: Re: diagnose this rpwalavalkar wrote: 22 yrs old, 35 wks pregnant, known VSD, history of haemoptysis, increasing dysponea and tiredness, collapses while trying to catch her 2 yr old who is running on the playground. clinical findings raised jvp, cool extremities, minimal urine output and marked hypotension??? the answer here is pulmonary hypertension _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:21 pm    Post subject: Nick Raine-Fenning wrote: A 30-year old parous woman presents to the antenatal clinic with a weeks history of feeling generally unwell and exhausted. She is hypertensive with a blood pressure of 140/90 and has a plus of protein in her urine. She is admitted for observation and despite her blood pressure remaining only slightly elevated developes epigastric pain, nausea and vomiting, and a headache. Her uric acid is mildly elevated and her platelet count is reduced at 60 x 10(9). Her clotting profile and haematocrit are normal but her haptoglobin level is low. hi nick, this is HELLP. the reduced haptoglobin is a dead give away. though i don't know how many will know that reduced haptoglobins = red cell destruction. raj _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:29 pm    Post subject: Nick Raine-Fenning wrote: A multiparous woman presents to her GP with malaise following a recent viral illness. hi nick, i am either way off target or spot on ............... cardiomyopathy ?? _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:33 pm    Post subject: Nick Raine-Fenning wrote: A 17-year old nulliparous student presents to her midwife at 34 weeks having just returned from travelling. She was scanned early on in her pregnancy and was shown to have a twin pregnancy. She develops a headache and becomes hypertensive. hi, my first guess here is Pre-eclampsia -- 17, nullip, twins, HT and headache. but you have not said proteinuria hence cant deny possible Acute hypertension. which is it? _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun Nov 26, 2006 4:44 pm    Post subject: Nick Raine-Fenning wrote: A 24-year old slim, nulliparous woman who had a vaginal delivery earlier that day complains of shortness of breath when lying down and palpatations. She has some chest pain and eventually coughs up a few flecks of blood. She is fit and well, does not smoke, and had an uneventful pregnancy and labour. On examination her JVP is raised but her blood pressure is normal at 125 / 65 and she is not tachycardic. Cardiac auscultation reveals a 3rd heart sound and a murmur suggestive of mitral regurgitation and there are inspiratory crackles over both lung bases. hi nick, shortness of breath when lying down, palpatations, chest pain, coughs up blood, JVP raised, S3, MR murmur and basal crepts all of the above point to CHF, could be bact endo or myocard infarct. in absence of febrile symp --- i'll vote for MYOCARDIAL INFARCTION what's the verdict??? _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Mon Nov 27, 2006 12:39 pm    Post subject: Re: brain teaser 1 So, if I am right ... Quote: 36 yr old, 30 wks pregnant, works in a paints factory, history of febrile illness since 3 days, had progressive loss cognitive ability, subtle personality changes, inability to concentrate, lethargy, nystagmus, loss of ability to swallow, seizures and progressive loss of consciousness and sinks in the ITU................. S - Encephalopathy Quote: 40 yr old, 14 wks preganant, died before the ambulance could reach her home, history taken from her partner was of ... a sudden onset of severe headache, nausea, vomiting, photophobia and neck stiffness, progressively unresponsive, her mother had also died of a similar horrible headache, she was also an essential hypertensive, diagnosed only a month prior to her pregnancy.......... Z - Subarachnoid Haemorrhage The subarachnoid one was fairly easy but the first one, encephalopathy was tricky. Could it be anything else? Guess the clinical scenario points to something intracranial. What about sepsis? Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Mon Nov 27, 2006 12:46 pm    Post subject: rpwalavalkar wrote: what's the verdict??? You'll have to wait! I am going to leave this for a day or two more as we have had several new members register and I am hoping they will start to post. Once we make a final answer it is harder to keep your brain open and it may just be that someone comes up with a different angle that we can use to improve the question. Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Mon Nov 27, 2006 5:34 pm    Post subject: hi nick, right on both accounts. the second one could be meningitis though now that u mention it, but i guess the family history seals the answer. raj _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Mon Nov 27, 2006 8:27 pm    Post subject: But is exactly what you need to do ... have questions that have a few possible answers but that one is the best answer. That makes your subarachnoid question a great question therefore. Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Wed Nov 29, 2006 9:48 am    Post subject: hi nick, please put me out of my misery. what are the answers?? raj _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Wed Nov 29, 2006 10:13 am    Post subject: Nick Raine-Fenning wrote: A multiparous woman presents to her GP with malaise following a recent viral illness. This is a tough one and open to debate but the answer is: Q HELLP syndrome It is essential to consider HELLP in any pregnant woman who presents with malaise or a viral-type illness in the third trimester. Reference: HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) presenting as generalized malaise. Tomsen TR. Am J Obstet Gynecol 1995;172: 1876-90. Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Wed Nov 29, 2006 10:45 am    Post subject: Nick Raine-Fenning wrote: A 17-year old nulliparous student presents to her midwife at 34 weeks having just returned from travelling. She was scanned early on in her pregnancy and was shown to have a twin pregnancy. She develops a headache and becomes hypertensive. F Pre-eclampsia Whilst I agree with your suggestion this could be D Acute hypertension it is important to go for the most likely and when you consider the key risk factors for pre-eclampsia, namely: Nulliparity Multiple pregnancy Maternal age less than 20 years or greater than 45 years Family history of pre-eclampsia Minimal prenatal care Chronic Medical Disease (Diabetes mellitus, Chronic hypertension) ...this swings it in favour of Pre-eclampsia here. Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Wed Nov 29, 2006 10:58 am    Post subject: Nick Raine-Fenning wrote: A 30-year old parous woman presents to the antenatal clinic with a weeks history of feeling generally unwell and exhausted. She is hypertensive with a blood pressure of 140/90 and has a plus of protein in her urine. She is admitted for observation and despite her blood pressure remaining only slightly elevated developes epigastric pain, nausea and vomiting, and a headache. Her uric acid is mildly elevated and her platelet count is reduced at 60 x 10(9). Her clotting profile and haematocrit are normal but her haptoglobin level is low. Q HELLP syndrome The clinical presentation is often vague although woman commonly complain of malaise (90%), epigastric pain and dyspepsia (60%), nausea and vomiting (30%), and headaches (30%). Examination may be entirely normal (say this in your essays) although patients may have abdominal tenderness epseically in the RUQ. Hypertension is often absent and when present may be mild. Proteinuria is not always present and rarely heavy. A low platelet count is one of the most important diagnostic parameters and HELLP should be considered in any pregnant woman who demonstrates a significant drop in her platelet count during the third trimester. Haematocrit can be normal but is often reduced and is usually the last thing to develop. A low haptoglobin can confirm haemolysis under these circumstances so well done for spotting this. The clotting profile is typical normal unless there is co-existent Disseminated Intravascular Coagulation. Uric acid is not a sensitive marker of HELLP. Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Wed Nov 29, 2006 11:07 am    Post subject: Nick Raine-Fenning wrote: A 24-year old slim, nulliparous woman who had a vaginal delivery earlier that day complains of shortness of breath when lying down and palpatations. She has some chest pain and eventually coughs up a few flecks of blood. She is fit and well, does not smoke, and had an uneventful pregnancy and labour. On examination her JVP is raised but her blood pressure is normal at 125 / 65 and she is not tachycardic. Cardiac auscultation reveals a 3rd heart sound and a murmur suggestive of mitral regurgitation and there are inspiratory crackles over both lung bases. P Cardiomyopathy Classic features apparently! If this presents more insidiously patients often complain of tiredness and a cough associated with gradual onset of orthopnoea and paroxysmal nocturnal dyspnoea. Chest pain may or mat not be present and some wome complainn of abdominal pain. Examination may be normal or reveal cardiomegaly, tricuspid regurgitation, severe peripheral oedema, ascites, thromboembolism, and hepatomegaly. Blood pressure can be normal. An ECG may be normal but usually shows signs of right heart strain with various arrhythmias. Whislt Myocadial Infarction and Pulmonary Hypertension are possibilities these are rare in someone previosuly fit and well who has had an uneventful pregnancy as is pulmonary embolism. Amniotic fluid embolus would be worth considering. Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Wed Nov 29, 2006 12:21 pm    Post subject: HELLP and cardio myopathy that should teach me to think basics first and not look for sensational diagnosis. raj _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1854 Location: Nottingham Posted: Wed Nov 29, 2006 12:25 pm    Post subject: I don't think you were sensationalising your answers - not at all. There is a lot of information to take in but often there are one or two words that really swing it in favour of one diagnosis. The low platelets and haptoglobin are suggestive of HELLP. The fact the woman was healthy and had an uneventful pregnancy point towards cardiomyopathy. A young, nulliparous woman with a twin pregnancy - got to be PET or a related event. Malaise, I grant you, was a bit unfair I still like it as it will ensure you think of HELLP next time. The good thing about these EMQs is that they help you write your essays. You need to be able to describe the clinical features of a disease, to be aware of which tests are diagnostic, and ultimately know which treatment(s) is appropriate. Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sat Feb 17, 2007 6:56 pm    Post subject: hi all, give this a try...... 42yrs old asthamatic, G4P3- 3SVD, at 34 weeks gestation, admitted with headache, visual disturbances, brisk reflexes, 3 beats clonus, total protein in ur 5gm%, right hypochondrial pain, has not passed urine in the past past 4 hrs and has a BP of 190/126. she is on a combination therapy for controll of HT. she develops an ecclamptic fit and is treated according to the unit protocol and delivered by LSCS post delivery, she starts complaining of tachycardia, increased difficulty in breathing not relieved by O2 + beta stimulants. her O2 stat keeps dropping she finally goes in to cardio - resp failure and dies. Why did she die?? _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top Abik Century Club Joined: 15 Jan 2007 Posts: 243 Location: Poole Posted: Sat Feb 17, 2007 7:35 pm    Post subject: OK so she has PET. Has she had a PE? (tachycardic and SOB) what is the relevance of beta stimulants? 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