Test yourself - Pelvic Bones

Test yourself  - All about pelvic bonesss

You think you know it all? Try these and prove it !

Q1. Name the pelvic lines 

Answer:

A: Ilioischial line

B: Posterior rim of Acetabulum(ischio-acetabular line)

C: Shenton line

D: Iliopectinal line

E: Roof of Acetabulum

F: Anterior rim of Acetabulum (acetabulot-obturator line)

G: Shenton line

H: Tear Drop

Q2. Name the structure below

Answers:

A:  Right hemi-pelvis
B: Left hemi-pelvis
C: Sacroiliac joints
D: Sacrum
E: Pelvic Ring
F: Pubic Symphysis
G: Obturator Foramen

Q3. Name the structure and muscle attached to it

 Answers:

1. Iliac crest - abdominal muscles
2. Anterior Superior Iliac Spine : Sartorius muslce
3. Anterior Inferior Iliac Spine : Rectus femoris muscle
4. Greater Trochanter: Gluteus medius and minima
5. Lesser trochanter: Iliopsoas
6. Ischial Tuberosity: Hamstrings
7. Pubic Symphysis: Adductors

Other Notes:

 Muscles connected to the pelvic bones. 

This is a post specifically to help you revise what you know about the pelvic area, specifically for orthopedics. 

This is very important and popular to be asked in exam. 

I am sure you already know this structures from medical school, hope this exercise helps you to remember them again😁

Good luck!

Unequal leg lengths : Limb Length Discrepancy

LLD : Limb Length Discrepancy

Limb Length Discrepancy (LLD)

Definition: where one limb is in a different length than its opposing limb, can be longer or shorter due to many causes.

Causes

1. Congenital (from birth)
2. Developmental:  can be from a childhood disease or injury that slows down or damages the growth plates
3. Post-traumatic

• Car accident that causes a fracture which leads to shortening of the bone ends)

How to attend to patient?

Intro:

• Confirm name, age
• Ask chief complain and other important history (any motor vehicle accident before?)
• Ask for consent and a chaperone if needed.
• Always be friendly and make patient comfortable.

Inspection

For 4 aspects when the patient is Standing → check front, side and back↔ check for DAWSSS

• Deformity
• Asymmetry
• Wasting
• Swelling
• Scar
• Straight

Gait

Ask patient to walk normally and to walk on heels and toes.

Types of gait to look out for:

• Short limb gait : dislocation of femur head or others -- confirm with bryant's triangle
• Tredelenburg : Gluteus weakness, can be direct or indirect
• Stiff knee : Osteoarthritis, Rheumatoid Arthritis
• Antalgic gait : Pain, Limping and lag gait
• High Stepping : Common among patient with peroneal nerve injury or palsy / sciatic nerve injury
• Others: Spastic(Cerebral palsy), scissoring(UMN issue)

Supine on bed : Lie flat and inspect 

If there are gait issue go straight to finding the source

Check apparent length

- Measure the length from xiphisternum to medial malleolus of left and right

- Compare both sides

Check True length

- measure from Anterior Superior Iliac Spine(ASIS) to medial malleolus
-Compare both sides

Interpretation:
True shortening>Apparent shortening: Deformity compensated by pelvis tilt
True shortening<Apparent shortening: Fixed Deformity without any compensation

If there is one side longer than the other(suspect injury above knee joint) perform the specific tests

1. Galaezzi Test

• Check for hip dislocation
• Check when the patient is in supine position. 
• Performed by flexing the knees while lying down so that the feet touch the surface and ankles at buttocks. 
• Check the tibial length by flexing knee 90 degree and ankle 45 degree

Interpretation:

• Shorter leg is the affected leg (femur head dislocated)
• Knee shifts cephalad(outward) when the femoral length is reduced, and caudally(inward) when the tibial length is reduced
• If it is parallel: LLD is below knee joint

2. Bryant's Triangle test

• to check LLD above knee joint

Line A: Line connecting the greater trochanter of femur with ASIS

Line B: Vertical line done from ASIS towards the bed (perpendicular with bed)

Line C: Horizontal line starting from greater trochanter to meet end of line B

(compare length of line C on both sides for diagnosis)

Interpretation: 

• diminution or increase in the length of line C : 
• to measure supra trochanteric shortening
• anterior or posterior displacement of the greater trochanter
• can be cause by: dislocation of hip, fracture of femur neck , hip deformity, intra-trochanteric fracture
• If both side are the same: the injury/ fracture might be in the middle of femur

Palpation and sensation

• Tone - Hip Knee Ankle
• Pain/tenderness - Hip, pubic symphysis, anterior superior iliac spine, axis, PSIS, greater trochanter
• Temperature of each part. 

Motor Examination

• Ideally would be to do a full motor examination, 
• If the patient is in pain, focus on the examination specific to the patient's issue. They will be grateful that you help them attend to the issue ASAP. 
• Range of movement for: hip, knee and ankle

Neurovascular Examination:

• pulse
• sensory
• example: wriggle toes and see if they can feel which toe is moving

Other special tests: 

• Thomas Test
• Check the fixed and flexion deformity of hip

• 1st picture is normal and 2nd is abnormal
• Ensure their lower back is flat. 
• Abnormal: Posterior thigh does not touch the table, knee flexion < 80 degrees

• Tredelenburg test
• examine strength of the abductor mechanism of hip
• One legged stance, if the weight bearing hip is unstable the pelvis drop to unsupported side

•  X-ray: check the AP view and lateral view

Ideally to take full history, examine spine and knee, access patient with radiography.

Other references:
1. http://www.limblength.org/conditions/limb-length-discrepancy-lld/
2. https://www.slideshare.net/ManishShetty8/clinical-examination-of-hip-122918037

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1796883/

Primary Dysfunctional Labor

Primary Dysfunctional Labor.

Definition

 - refers to inadequate uterine contractility to maintain appropriate progress in labor
 - adequate uterine contraction pattern is one in which there are four to five concerted synchronous contractions every 10 minutes
- poor progress during active phase of labor : cervical dilation <1cm/hour for 2 consecutive hours

Diagnosis 

• Using partogram
• Usually mother in primary dysfunctional labor will have these shown in partogram, the one shown below is one of the examples.

https://www.slideshare.net/MohdHanafi1/13-partogram

Partogram reading samples can be like this:

• Contraction inadequate and deviated in the first 3 hours
• Station remain high after 10 hour in labor
• Cervical contraction arrested beyond action line

Make sure you diagnose them correctly and able to differentiate between prolong latent phase, primary dysfunctional labor and secondary arrest:

Causes:

1. Maternal factors:

• Inadequate pelvis size
• Liquor volume low
• Pelvis contraction inadequate
• increase stress

2.  Fetal factors:

• Malposition if the baby
• Macrosomic fetus
• Malpresentation
• Fetal Anomaly

3. Placental factors

4. Physical restrictions (position in bed)

5. Premature or excessive analgesia particularly during latent phase

Management:

• Admit mother and keep her under close observation
• Monitor the mother and baby vital signs
• IV line fluid and Oxygen supply
• Order blood test - Full blood count, amylase, urine and electrolytes
• Order CTG and ultrasound to confirm baby position
• Full abdominal examination and vaginal examination

Further Management:

• Oxytocin 
• Constant monitoring using CTG 
• Maintain mother's oxygen level
• Reposition the mother
• IV fluid 
• C-section (if no changes 2-4 hours after maximum oxytocin dose achieved)

Obstetric Examination Checklist

Obstetric Abdominal Examination Checklist

What should we do when we have a pregnant lady that needs physical examination?

The checklist below is a guidance to what you must do to make sure both the mum and baby are healthy and safe.😌

However every hospital have a different checklist, you need to make sure you do what the professor is expecting you to do. 

In all Physical Examination checklist there must be 5 aspects be done from

1. Introduction and consent

2. Inspection

3. Palpation

4. Auscultation

5. Presentation

If you panic during the exam, always think of this 4 aspects, and you will remember what you need to do.

Introduction

• Introduce yourself 
• Explain why are you here (to examine her and her baby's well being)
• Ask the patient to get ready. eg: to have proper exposure of her tummy and lie on her back facing upwards.
• Wash your hands and prepare instruments needed for the checkup

Inspection checklist

• Abdominal distension (is it normal distension or abnormal)
• Shape of uterus
• Scar / Linea nigrae/ Striae
• take note of the surgical scar (can be from C-section)
• Is it healed? or keloid form?
• Any fetal movements visible?

Palpation

• Superficial
• Tenderness?
• Fetal movements
• SFH - symphysis fundal height 
• Important to determine if there are any abnormalities, eg. :
• Big: multiple pregnancy, growth restriction, polyhydramious
• Small: FGR, oligohydramious
• Fundal grip
• Lateral grip
• Pelvic grip

• Fetal Lie
• transverse? longitudinal? or oblique?

• Palpate the fetus size softly to determine his position by checking:
• upper pole - is it round? soft?
• lower pole - hard? globular?
• Left side - soft broad curved structure? (back)
• Right side - Irregular structure? (limbs)

• Confirm any head engagement
• Are there adequate liquor 

Auscultation

• check fetal heart rate using fetoscope

Presentation - what to explain

Step 1

• Uterine contraction presence
• Uterus correspond to date
• Any breech? and explain

• type of lie, usually longitudinal.
• cephalic presentation?
• head engagement?
• adequate liquor ?

 For example: The fetal lie was longitudinal with a cephalic presentation noted to be 4/5th palpable on abdominal examination.

Step 2

• present SFH eg. the measurements

Step 3

• Fetal HR
• surgical scar 
• EFW
• Liquor volume

Step 4

• Gather information about delivery history
• successful vaginal delivery? c-section? what are the indications/ complications? weight of the previous baby.
• Suggest further assessment
• ultrasound to confirm location
• cardiotocogram - exclude fetal compromise
• vaginal examination
• give appropriate counsel
• eg: on VBAC benefits, success, complication compare to LSCS
• reassure patient and thank them. 

A video to help you understand better:
https://www.youtube.com/watch?v=-pkkgBX7OFQ

Obstetric history checklist in OSCE

Obstetric "To ask" checklist / History Taking. 

We often feel clueless or unsure what to ask when we are in the obstetric department.
This post is an example of the template I had in my notes while I am in med school, just want to share with everyone.
There are 10 aspects we can ask from to understand them better.
All of them are for references only, use them wisely😀

Demographic

• Name, Age 
• Occupation
• Ethnic
• Chief Complain

Current Pregnancy History

• Gestation , LMP/EDD
• Date from ultrasound
•  Single/Multiple chorionicity
• Details from Chief Complain
• What action has been taken
• any other problems
• any bleeding, contraction or loss of fluid vaginally?
• Is there a plan for the rest of the pregnancy

Ultrasound History

• What scan? why?
• Any problems?

Past Obstetric History

• List of previous pregnancy
• G. P. A.
• Vaginal birth or C-section
• complication?
• baby weight
• Full Term? Pre-term.
• Baby's condition. eg. bluish, difficulty breathing,,, 

Gynecology History

• Periods history
• when is the last period
• any abnormal or irregular menses. 
• Contraceptive history
• Previous infection and treatment did
• When is the last cervical smear or screening. Is it normal ? and any treatment?
• Any history of surgery

Post medical and surgical

• Any medical related issues. eg. IDA, diabetes...
• any previous operations?

Psychiatry

• Postpartum Blues
• Depression
• Major illness, eg: schizo

Family History

• Diabetes
• Hypertension & etc. (chronic illness)
• Psychiatry
• Genetic

Social history

• Smoking/ alcohol/ drugs, etc...
• Marital status and their relationship
• Partner's occupation
• Financial status. eg: any helper at home? etc. 

Drug History

• Any folate supplement used (for pregnant lady)
• Allergies to food/ medicine 
• if yes, what are the symptoms.

SO that's all that you need to ask whe you approach a pregnant lady. Every lady has a different situation and problem, so you will also need to make a decision which question you would like to "double click" and understand more about the details that you need to make a primary diagnosis. 

Hope this article helps, Good luck!

USM Exam Part II Experience 2019

Examination for provisional registration

Date of exam                      : 3rd December 2019

Date of Intensive class       : 1st and 2nd December 2019

Duration                             : 3 days in HUSM

Transport                            : Flight from KL to Kelantan (around RM 500)

Exam Cost                          : RM 3000 for the exam, RM 1000 registration 

Utility Cost                         : Food RM100, USM Guest House RM 75/night (shared a double room)  

Past Year Question link      : USM 2019 Dec
Things to pack along          : Lab Coat, Stethescope, Pens, Snacks and sweets, Formal attire
                                              (pentorch, hammer will be provided if it is required in the station)

What happens after you pass?

So after you pass, you will need to wait for about 2-3 months before they give you a call to let you know the next exam date. DO NOT wait until they call to start studying, it will be too late >.<

After I receive the call, they send me the letter two weeks later (around 5th November). And we will need to:

 - confirm if we are going to take the exam

 - confirm if we are attending the intensive class

 - make payment

Letter Head of the Offer Letter

Part of the Letter

Accomodation

-They do not provide accommodation for us, so we call a few numbers below to ask for availability. If you know a friend who is taking the exam together, you can share a room with them. It helps to improve the atmosphere, or you will be nervous all the time, plus you will have a study partner too! 

After consideration, we choose to stay in rumah tetamu USM, it was more expensive but the room is bigger.

The double room we had even has a balcony and a pantry area.

I had a picture of the bed below, please ignore the mess we made. XP

Usm Guest House 

Itinerary

We reached one day earlier to settle in and get use to the place. It depends on you if you need it or not.

On the first day we are require to go to this pusat sumber pelajar for a briefing. It was in Hospital USM itself. Remember to bring a jacket, it is quite cold for me.

They also gave us a schedule of what we would be doing for the rest of the day, so we can get prepared. We are being reminded that this intensive course is not a class to teach medicine from A to Z, but a class to help us get use to how the osce is going to be done (such as the scoring, what they expect us to do in the exam venue, quick summary on what the examiner expect when you see them on the exam day). 

The intensive course was really useful, it help a lot to make us get use to the environment and the exam style. 

Intensive course Venue

Schedule for 3 days

Tutorial Hall

Practice Session
We are given some time to practice on manikins in a room (I am not sure what they call it)

Where is our exam hall? 

The pictures shared above is a sneak peak to where our exam was conducted. It was scary at first, but soon you will get use to the flow. I enjoyed the OSCE exam more then the theory, because it reminds me of my days as a student taking my final exam during my university years. So glad to be able to be one step closer to my dream after a year of waiting and studying!

If you want to know about how it was being conducted, check out this link.

Take Home Tips

- Read the questions properly. Think and try to recall the information you want to ask and present. 

- Always start with greeting, introducing yourself and wash your hands!

- Build good rapport and have eye contact with patient, respect the examiner as well.

- Take patient identification data! (name, age, marital status, occupation) follow by their chief complain

- Balance with open and close ended questions about the assessment. especially : mental assessment, suicidal risk, OCD criteria, trauma related. -- they are very important and often carry high points
- Always say thank you to the patient and also the examiner
- I know you will be nervous in the room, but try present your finding as organised as possible, so the examiner can understand you and it helps you with your diagnosis too!

I wrote a post on what came out on that day, you can learn more from here.

So try your best and have fun in the exam! You will meet a lot of new friends who are in the same situation. Get their contacts and keep in touch😁

Enjoy and pass the exam with FLYing colours!