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MEQ2. Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she
has been trying to be pregnant, but all her trials ended by failure. This time she succeeds and
she became pregnant. She came to you for her first antenatal visit at 10 weeks gestation.
MEQ3. Two days later Mrs. Sabreen came to you complaining of vaginal bleeding.
MEQ4. Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a
very luxurious hotel. He noticed white spots spreading in his hands and trunk which was
diagnosed by a competent dermatologist as vitiligo, but Mr. Waseem did not accept the
diagnosis and he came to you asking for referral to another dermatologist.
MEQ5. You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for
DM.
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I will find out the real reasons for his attendance & the effect of the problem
o His idea
o His concern
o His expectation
o I will take full history
o I will do general examination
o I will look for the differential diagnosis
Is it physical?
Is it social?
Is it psychological?
I will look for risk factors like smoking, obesity, hyperlipidemia, DM – hypertension,
asthma, drug, abuse, sedentary life …
I will choose with the patient the appropriate action for each problem.
Management option:
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ANSWER MEQ2:
Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she has been
trying to get pregnant, but all her trials ended by failure. This time she succeeded and she
became pregnant. She came to you for her first antenatal visit at 10 weeks gestation.
Physical Examination:
General inspection: Pallor / Odema
Vital sign: Pulse / BP
General examination: Chest & CVS / Breast /Abdominal examination
OB examination: Vaginal examination if needed
Psychological Assessment:
Patient ideas She may think she needs traditional healer to save her
pregnancy.
She might think that this is afalse pregnancy or tumor
or ascitis, it is not a real pregnancy!
She may be thinking it is a twin pregnancy because of
ovarian stimulant medications.
Social support:
Relationship with her husband & his attitude towards
this pregnancy.
The condition at work (if she is working) and if there is
any risk needing to be avoided e.g. heavy work.
Management options :
Reassurance: Patient needs explanation & reassurance that she is in good hands
and if any problem raised it will be diagnosed early and she will got the
maximum treatment available.
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ANSWER MEQ3:
Two days later Mrs. Sabreen came to you complaining of vaginal bleeding. Discuss your
management of this situation.
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Expectations : Treatment to stop this bleeding and save her pregnancy.
D & C because she might think she already lost the baby.
Referral to a special center to do anything to save her
pregnancy.
Sick leave to give her a chance for complete bed rest.
Social resources : Family support by her husband or mother or sisters or
friends.
Support at work because she is physically & psychologically
fragile.
Risk assessment :
Symptoms of depression e.g. her mood and interest in life.
Symptoms of pathological anxiety e.g. palpitation and
dyspnea.
Bereavement (state of shock & denial).
Immediate Managements :
Management options:
Reassurance : Explanation of the findings and reaching
shared understanding of the situation: If it is
threatened, complete or incomplete abortion.
Investigations : CBC to assess the degree of chronic bleeding
Urgent US to establish the diagnosis of
abortion
HCGT if low it may indicate abortion
Specific Treatment :
threatened Bed rest may help but there is no Evidence
abortion : Based Medicine supporting this advice (EBM).
Hormonal treatment may help, but there is no
Evidence Based Medicine supporting this
treatment.
Grate proportion of patient with threatened
abortion can complete there pregnancy to the
end.
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Anticipatory Care : If Mrs. Sabreen lost her pregnancy, she will
need close observation during bereavement for
early diagnosis of abnormal bereavement
reaction & appropriate intervention, e.g. Referral
to psychiatry
If the diagnosis is threatened abortion, she
need social support & reassurance from her
husband and /or relatives to complete her
pregnancy
Self awareness:
My feelings : I may feel anxious in dealing with life threatening
situation (bleeding)
I may feel depressed if Mrs. Sabreen lost her pregnancy
I may feel helpless if the diagnosis is threatened abortion
and there is no effective (EBM) treatment which I can offer
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ANSWER MEQ 4:
Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a very luxurious
hotel. He noticed white spots spreading in his hands and trunk which was diagnosed by a competent
dermatologist as vitiligo, but Mr. Waseem did not accept the diagnosis and he came to you asking for
referral to another dermatologist.
Patient factors:
Patient Ideas: Vitiligo is an infectious disease & it may affect his
family.
It is an acute illness and he will find radical treatment
for it by an expert dermatologist.
It is a very serious illness & may progress to skin
cancer.
Patient Concerns: He may loss his wife because of this disease and also
his friends.
Losing his job in that luxurious hotel.
He cannot find another job because no body likes his
appearance.
The treatment is expensive and he can not afford its
cost.
The disease may be hereditary & it will affect his
children.
His daughters will be stigmatized and no body will
come to marry them.
Doctor factor : The PHC physician may not have enough time to
discuss his worries with him.
Lack of trust between the patient and his PHC
physician.
Dependent Dr – Pt relationship makes the patient
think he can ask for anything any time.
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The health care system :
Flexibility of the referral system allows multiple referral.
Different hospitals have different resources so the patient is asking for a
better hospital with more resources e.g. not every hospital has laser
treatment.
Physical assessment:
History: Painless depigmentation of the skin.
Hair changes in the affected area (becoming
white).
Family history: Similar disease in the family
Precipitating factors: Psychological stress at work or at home
Risk assessment: Possible associated autonomous disease e.g.
Thyroid disease, Pernicious anemia, DM,
Alopecia arietta in the patient and / or his
family.
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Explanation & reassurance: The disease is not uncommon, it is not
infectious.
The disease is autoimmune, usually has no
complications, there are different treatments for
this disease, but no radical treatment e.g.
Potent topical steroids, PUVA, sunscreens,
Disagree with Mr. Waseem : cosmetic camouflage.
(No need for referral at all), but this option
may affect Dr. – Pt. relationship and also it may
Agree with Mr. Waseem : deny from him the benefit of another expert
opinion.
(refer him directly to another dermatologist).
By this option I may express my sympathy &
support and maintain Dr. – Pt. relationship.
But it may make patient dependent, it might
be a waste of resources (unnecessary referral).
The dermatologist may become angry from
my behavior.
Self awareness:
My feelings:
Mr. Waseem might make me feel sad &
depressed because of the effect of vitiligo in his life.
He may make me feel angry because of his
demanding behavior.
I may feel helpless because there is no radical
treatment for his disease.
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ANSWER MEQ 5:
You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for DM.
Assessment of needs :
What are the prevalence of DM and what are the
priorities in this health center
What are the needs of the population in the
catchment area of this center ? e.g. if they are
mainly young, they may need mini-clinic for
asthma more than DM or we may need to improve
vaccination clinic before starting a new mini clinic.
Assessment of Resources :
Man Power : Trained and interested nurse.
Trained and interested doctors.
May be social workers and / or dietitian.
Lab technicians.
Trained receptionist.
If they are not trained, they need special training
before the center can start the clinic.
Community Participation :
The opinion of the community should be taken in to
consideration
The role of the community may be discussed : e.g.
their role in offering some help to get the necessarily
equipment, and their role in compliance
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Arrangement of routine referral to hospital
Time : how many sessions per week ? what sort of
appointment system
Space : in the dr. consultation room or special room
for the clinic
Staff : special staff for the clinic or every doctor take
care of his diabetic patient
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