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OBSTETRIC CLINICAL REASONING EXERCISE DISCUSSION
Below is a clinical reasoning exercise in obstetric medicine. It's fairly straightforward, so read the information and then answer these questions:
1) Give the 2 major disturbances present in this patient's pathology.
2) What is the most likely diagnosis?
3) Give 3 other investigations you wish to perform and the indication for them.
1) Give the 2 major disturbances present in this patient's pathology.
2) What is the most likely diagnosis?
3) Give 3 other investigations you wish to perform and the indication for them.
IPAD Users:
| o_g_clinical_reasoning_week_2.pdf |
1) Give the 2 major disturbances present in this patient's pathology.
1. Severe derangment of transaminases (ALT & AST) in comparison to other liver enzymes and bilirubin
2. Metabolic Acidosis (low bicarbonate)
Comment: this is an example of "bracketing" your answer that was discussed in week 1. Reasonably, one could specify that the 2 major derangements are ALT and AST, however this ignores the other major abnormality present (the low bicarbonate). Thinking from a strategic perspective answering as we have done ensures that we have specifically mentioned both transaminases and the bicarbonate
2) What is the most likely diagnosis?
Preclampsia complicated by HELLP (Haemolysis, Elevated Liver [enzymes], Low Platelets) Syndrome.
Again, a question that illustrates the importance of a "consultoid" answer. Writing "pre-eclampsia" alone is unlikely to score marks. Specifying HELLP syndrome - the entire point of giving a candidate the pathology data in the first place! - is essential. However, explicitly stating that the patient is also pre-eclamptic, remembering that HELLP syndrome defines severe pre-eclampsia, leaves no doubt in the examiner's mind that the candidate knows what they are talking about. This is an example of using few words to say a great deal.
3) Give 4 other investigations you wish to perform and the indication for them.
1. Full blood count: check Hb (haemolysis) and Platelet count (thrombocytopaenia)
2. Coagulation profile: exclude DIC
3. VBG: define pH and acid base disturbance
4. Urine dipstick: check for proteinuria.
As in most questions, the third part should really be set up by the first two. Candidates who have correctly recognised the disturbance and made the provisional diagnosis should have little trouble writing something sensible very quickly. Often, you should aim to be quick with the third part of a question in the interests of time preservation for the rest of the exam.
1. Severe derangment of transaminases (ALT & AST) in comparison to other liver enzymes and bilirubin
2. Metabolic Acidosis (low bicarbonate)
Comment: this is an example of "bracketing" your answer that was discussed in week 1. Reasonably, one could specify that the 2 major derangements are ALT and AST, however this ignores the other major abnormality present (the low bicarbonate). Thinking from a strategic perspective answering as we have done ensures that we have specifically mentioned both transaminases and the bicarbonate
2) What is the most likely diagnosis?
Preclampsia complicated by HELLP (Haemolysis, Elevated Liver [enzymes], Low Platelets) Syndrome.
Again, a question that illustrates the importance of a "consultoid" answer. Writing "pre-eclampsia" alone is unlikely to score marks. Specifying HELLP syndrome - the entire point of giving a candidate the pathology data in the first place! - is essential. However, explicitly stating that the patient is also pre-eclamptic, remembering that HELLP syndrome defines severe pre-eclampsia, leaves no doubt in the examiner's mind that the candidate knows what they are talking about. This is an example of using few words to say a great deal.
3) Give 4 other investigations you wish to perform and the indication for them.
1. Full blood count: check Hb (haemolysis) and Platelet count (thrombocytopaenia)
2. Coagulation profile: exclude DIC
3. VBG: define pH and acid base disturbance
4. Urine dipstick: check for proteinuria.
As in most questions, the third part should really be set up by the first two. Candidates who have correctly recognised the disturbance and made the provisional diagnosis should have little trouble writing something sensible very quickly. Often, you should aim to be quick with the third part of a question in the interests of time preservation for the rest of the exam.