A 26-year-old female presents to clinic complaining of increasing headaches for one year, irritability, bloating and fluid retention, and abdominal discomfort with loose stools during her menstrual cycle. The symptoms begin a day or two before her menses, and last until the middle of her cycle. She has tried acetaminophen and ibuprofen without improvement. On physical exam she is a well-developed, well-nourished female in no acute distress. Vitals are normal, CV and lungs are normal, pelvis exam is normal, pap smear is normal, and GC and Chlamydia testing are negative. What would be the most appropriate next step?
A. Pelvic ultrasound
B. FSH, LH levels
C. Fluoxetine on cycle day 21-7
D. Paroxetine daily
E. Serum HCG
A 21-year-old female presents to clinic complaining of mild, low abdominal ache and intermittent dysuria. She denies N/V/D, and she is sexually active and uses condoms some of the time. Her LMP was 10 days ago, and she is a G0P0. Physical exam reveals a healthy female in no acute distress. Vitals are as follows: P 70, BP 120/80, T 99.9°F. Lungs are clear, CV RRR, abd soft non-tender, + BS. Pelvic exam reveals normal external genitalia, scant discharge, moderate cervical motion tenderness, and no adnexal masses. What is her most likely diagnosis?
A. Tubo-ovarian abscess
C. Ectopic pregnancy
E. Pelvic inflammatory disease
D. a 37-year-old woman who smokes 2 packs per day and has a history of hypertension
In the majority of cases, a combined hormonal contraceptive (ie, one that contains both an estrogen and progestin) is the preferred method of oral contraception because of its efficacy when used perfectly (>99%). However, for women older than 35 years of age who are smokers or are obese, or who have a history of hypertension or vascular disease, progesterone-only contraceptives are recommended. Ethinyl estradiol (EE), the most common estrogen found in combined hormonal contraceptives, has been associated with an increased risk of myocardial infarction in women older than 35 years of age who are smokers. Additionally, EE has also been shown to cause increases in blood pressure in both normotensive and mildly hypertensive women. Progestin-only contraceptives, however, tend to be less effective than the combined hormonal contraceptives.
D. Serum TSH level
The correct choice is D, serum TSH level. This patient is presenting with post-partum thyroiditis. Thyroid dysfunction occurs in 2 to 5% of women after giving birth. It can recur with subsequent pregnancies and develop into long-term thyroid disease as well. Typically, women with this disorder first develop signs and symptoms of hyperthyroidism, which then later changes to hypothyroidism. Most symptoms resolve spontaneously within a few months. In the hyperthyroid stage of this disorder, blood tests will reveal a suppressed TSH level with elevated serum thyroid hormone levels, as is common in all forms of primary hyperthyroidism. Choice A, a radioactive iodine uptake test, would reveal little or no uptake, but this test should not be ordered in a woman who is breastfeeding. For choice B, a serum total T 4 level can be elevated, but is not as sensitive or specific as TSH as a screening test. Any protein status changes in the woman can cause an elevated total T 4 without any thyroid dysfunction. Choice C, a thyroid fine needle aspiration, can be performed, but is not likely necessary and would not be the best next step for this patient. Choice E, an MRI of the anterior pituitary, would only be suggested if there is a suspicion of a pituitary tumor. This is a rare cause of hyperthyroidism and would not be the best next step.
A 37-year-old female presents to the labor and delivery department complaining of intermittent pain and contractions. Upon arrival, she also complains of vaginal bleeding. She is a G3P2 at 39 weeks gestation; no other prenatal complications are noted. She is a non-smoker. A physical exam reveals the following: P 90, BP 130/80, T 98.7°F, abdomen gravid, positive bowel sounds, and left lower quadrant tenderness noted. A sterile speculum exam reveals the cervix to be dilated 8, fetus is cephalic, and membranes are intact. The fetal monitor reveals heart tones in the 140s with mild, decreased variability and good quality contractions noted. Delivery is felt to be imminent, and vaginal delivery has been determined to be the best course of action. What will likely decrease bleeding and shorten time to delivery?
A. Increased activity level
C. Oxytocin therapy
D. Epidural placement
E. IV sedation
A .Gram negative bacillus
Chancroid is a common sexually transmitted disease in developing nations, but is relatively rare in the United States. Chancroid is caused by Haemophilus ducreyi, a gram negative bacillus, which has an incubation period of 4 to 10 days. Initially, a small pustule will form at the site of inoculation and progresses to multiple, painful ulcerations with sharply demarcated purulent bases. The number of ulcers and the pain associated with the ulcers are the distinguishing features of chancroid and differentiate it from syphilis. Chancroid is also associated with painful inguinal lymphadenopathy, termed a bubo, which is unilateral, large, painful, fluctuant and may become suppurative.
Treatment is with Azithromycin 1 gm orally once, ceftriaxone 250 mg intramuscularly once, ciprofloxacin 500 mg orally twice a day for three days, or erythromycin 500 mg orally four times a day for 7 days.
D. Pelvic ultrasonography
Determining the source of abnormal uterine bleeding is a difficult task when caring for gynecologic patients. This evaluation begins with a detailed history and physical followed by laboratory tests and pelvic ultrasound. Common initial laboratory tests include a complete blood count, serum prolactin level, serum ß-hCG and serum thyroid stimulating hormone level. Pelvic ultrasonography may reveal uterine lining abnormalities, including irregularities, polyps, fibroids and masses. The results of the above will guide the clinician down a non-gynecologic versus gynecologic pathway.
If a gynecologic source is suggested, endometrial biopsy (B), which can be accomplished via many different curette procedures, is then recommended. If the source of bleeding is still not found, hysteroscopy (C), which allows direct visualization of the uterine cavity, is then recommended. If the diagnosis is still unclear, the patient may be sent for dilatation and curettage (A). This procedure's sedation allows for muscular relaxation which may increase diagnostic yield.
A. Begin work-up for primary amenorrhea
Primary amenorrhea is defined as failure of menarche by age 16 in a woman with apparently normal sexual development or by age 14 in a woman with no secondary sexual characteristics. Secondary amenorrhea is failure of menstruation after normal menses are established, with the caveat that at least 3 months have passed with apparently normal menses or 9 months have passed in a woman with oligomenorrhea. Primary amenorrhea can be caused by obstruction of the outflow tract, androgen insensitivity, gonadal dysgenesis, hyperprolactinemia, and dysfunction of the hypothalamus, pituitary, or thyroid. To evaluate a patient with primary amenorrhea, after a thorough clinical history, the physical examination must focus on development of secondary sexual characteristics (breast development, pubic, and axillary hair).
A 40-year-old woman with a history of asthma presents to the ED with symptoms of wheezing and shortness of breath similar to previous exacerbations. Her vital signs are BP 115/70, HR 80, RR, 14, and pulse oximetry is 99% on room air. The patient is offered and agrees to a point-of-care beta-hCG test that returns positive. On exam, you note mild bilateral wheezing with good air movement. Pelvic exam reveals a closed os without adnexal tenderness or masses. Which of the following is the most appropriate next step in management?
A. Delay treating her asthma until her pregnancy status is further clarified
B. Treat her asthma as indicated, and perform a beta-hCG quantitative level
C. Treat her asthma as indicated, if improved, discharge with outpatient obstetrical follow-up
D. Treat her asthma as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound
B. Suction curettage
Postpartum hemorrhage can be a serious, and sometimes fatal, situation. One of the causes is retention of placental tissue, which is usually due to abnormal placental implantation or an abnormal separation process. Delivery of an incomplete placenta, for example one that is abnormally shaped or missing some of its normal septations (cotyledons), may prevent normal postpartum uterine contractions. This can lead to improper constriction of the spiral arteries (uterine atony), and ultimately, excessive bleeding. If retained placenta is a highly suspected cause of postpartum hemorrhage, immediate digital extraction should be performed by inserting fingers thru the cervix and into the uterus, then using them to direct and maneuver any remaining intrauterine tissue out through the vagina. If this is unsuccessful, and bleeding continues or the patient decompensates, curettage with a suction device or sharp curette is recommended. Adjuvant interventions include establishing large-bore intravenous access, uterine massage, oxytocin, methylergonovine maleate and alerting the operating room.
Obtaining a blood type (A) and alerting the blood bank is wise in managing any patient with hemorrhage. However, in this case, it should not supersede a definitive treatment like curettage.
C. Medroxyprogesterone acetate
Contraception counseling should be routinely performed in all women of child-bearing age at every annual visit. There are many options such as behavioral, barrier and pharmacological methods. However, pharmacological therapy has the highest rate of pregnancy prevention and should be recommended in all women, unless there are contraindications. This patient has a history of migraines with aura which is considered a contraindication to estrogen use. Other contraindications to estrogen are history of deep vein thrombosis, breast cancer within the past 5 years, cigarette smoking in women more than 35 years of age who smoke more than 15 cigarettes per day, ischemic heart disease, stroke, active liver disease, major surgery with prolonged immobilization and poorly controlled hypertension. In these cases, progesterone only therapy (medroxyprogesterone) should be used in the form of the intrauterine device, the injection or the subcutaneous implantation in the arm.
D. Premenstrual syndrome
This patient displays some of the common symptoms of premenstrual syndrome, a poorly understood condition of physical, mood and behavioral changes which occur during the second half of the typical 28-day menstrual cycle. On average, menstrual flow lasts 4-5 days, beginning on day 1 of the menstrual cycle (the beginning of the follicular phase), and ending on day 4 or 5. Around day 14, ovulation occurs, and the second half of the cycle, the luteal phase, begins. If the oocyte is not fertilized, the luteal phase, on average, ends around day 28. Subsequently, a new cycle commences with the onset of another menses. The symptoms of premenstrual syndrome occur in this second half period (day 14-28), most commonly occurring on day 23-27, which is typically 18-19 days after the last day of the most recent menstruation.
A. Anger and irritability
Premenstrual syndrome (PMS) is not clearly defined, as its high prevalence, unclear etiology and myriad of symptoms makes it difficult to classify it as a disease or a cluster of physiologic changes. Age of presentation is mainly in the late 20s to early 30s, and it recurs in up to 75% of affected women. Etiological theories include psychological disturbance, alterations in estrogen and progesterone balance as well as serotonin function, hypoglycemia and hyperprolactinemia. Symptoms include headache, insomnia, fatigue, low energy, bloating, breast tenderness, abdominopelvic pain, depression, anxiety, dysphoria, mood lability, appetite changes, crying episodes, confusion, poor coordination and poor concentration. Symptoms typically interfere with the woman's daily life. According to the American Psychiatric Association DSM-IV, prominent anger, irritability and internal tension associated with severe premenstrual syndrome symptoms is defined as premenstrual dysphoric disorder
B. Primary amenorrhea
Primary amenorrhea, seen in approximately 2.6% of the population, is defined as absence of menarche by age 16 in a woman with normal growth and secondary sexual development, or age 14 in a woman without normal growth and secondary sexual development. Secondary amenorrhea, in women who have previously menstruated, is defined as absence of menses for more than 3 cycles or 6 months. The most common cause of primary amenorrhea is caused by gonadal dysgenesis due to a chromosome abnormality, while other causes include hypothalamic disease, pituitary disease, abnormal hymen (as in the patient above) or vagina development or uterine agenesis. The patient may have a family history significant for sexual development abnormalities. The most common cause of secondary amenorrhea is pregnancy, followed by abnormalities of the hypothalamic-pituitary-ovary axis, thyroid disease, and ovarian or uterine disorders.
C. Schistocytes, thrombocytopenia, and elevated aspartate aminotransferase and alanine aminotransferase > 500 U/L
HELLP syndrome is an important clinical variant of preeclampsia with Hemolysis, Elevated Liver function tests, and Low Platelets.HELLP syndrome is confirmed with laboratory testing, which shows microangiopathic hemolytic anemia (low hemoglobin and schistocytes on blood smear), thrombocytopenia, and elevated liver function tests, including elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and lactate dehydrogenase. AST and ALT levels are typically double the upper limit of normal. The management of HELLP syndrome involves bed rest, blood pressure management, and magnesium sulfate for prevention of eclamptic seizures.