Dissecting a PBL Case - Worked example

Following the suggested schema:

Click here Analysing PBL cases

Patient case

34 yo unemployed mother in defacto relationship presents with nausea. Transient episode of vomiting 2 weeks previously. Usually healthy. Has been amenorrheic past 8 weeks after ceasing pill. She complains of worse than usual breast tenderness. There is a family history of Type II diabetes. She has a two children with both children born in the > 90th percentile. The second one suffering mild neonatal hypoglycaemia.

On examination, she is significantly obese. Gyanecological examination reveals an modestly enlarged uterus and tender left adnexa.

A number of laboratory investigations were performed were normal. An ultrasound confirmed a pregnancy and showed no other abnormality. Later an oral glucose tolerance test demonstrates intolerance. Dietary modification is recommended and she is given a home gluocose machine but remains poorly compliant resulting in unstable glucose control. Diabetic nurse input is sought.

Physical examination at 34 weeks shows a large for dates baby and the head has yet to engage. The ultrasound confirms fetal macroscomia.

At 38 weeks the patient spontaaneously enters labour and delivers a 4.2 kg male infant vaginally with moderately low APGARs. The infant requires IV glucose for 12 hours for low blood sugars but neither mother or child suffer further complications. Six weeks later repeat glucose tolerance test is normal.

Key words

Symptoms (patients complaints) - nausea, vomiting, amenorrhea, breast tenderness

Signs (findings by examination) - obesity, uterine enlargement, tender adnexa, fetal macrosomia, low APGAR scores

Measured physiological parameters - hypoglycaemia

Investigations - fetal ultrasound

Diseases / Conditions - Maternal diabetes

Treatments - IV glucose

Learning issues

• What is amennorrhea?
• Define the normal menstrual cycle?
• What mechanisms produce the normal menstrual cycle?
• By what mechanisms can the menstrual cycle be disturbed?
• By what mechanisms can cause the menstrual cycle to stop?
• What are clinical causes of ammenorrhea?

• What is maternal diabetes?
• What is the mechanism by which this occurs?
• What are causes - predisposing, perpetuating or precipitating causes?
• What complications can occur?
• What is the treatment?
• What is fetal macrosomia?
• What are the mechanisms by which macrosomia occur?
• What are the possible complications? How are these managed?

Several dozen learning issues can be developed from any case e.g. a detailed treatment of obesity, APGAR scores or blood glucose regulation.

The actual learning issues for the week are NOT entirely predictable and tutor guidance is required to target the key points of the history. Occasionally there is a focus on normal physiology and other times it may be on pathology.