Case Files - Approach To The Patient Flashcards
Pregnant women younger than 17 or older than 35 are at increased risk for
Preterm labor
Preeclampsia
Miscarriage
Gravidity
Number of pregnancies including the current one.
Includes miscarriages, ectopic pregnancies and stillbirths
Parity
Number of pregnancies that have ended at gestational age >20 weeks
Abortuses
Number of pregnancies that have ended at gestational age
Clinical Pearl -
G T P A L
Gravidity Term Deliveries Preterm Deliveries Abortuses Living Children
LMP
The FIRST DAY of the last menstrual period. Important in determining gestational age.
Expected Due Date
LMP - 3 months + 7 days
Chief Complaint: Postmenopausal bleeding
What are you most worried about?
Endometrial cancer
What are the risk factors for endometrial cancer?
Hypertension Diabetes Anovulation Early age of menarche Late age of menopause Obesity Infertility Nulliparity
What should the first line of every obstetric presentation include?
Age Gravidity Parity LMP EGA Chief Complaint
Age of menarche - Normal range
9 years old - 16 years old
Interval from first day of one menses to the first day of the next - Normal range
21 to 35 days
Quality of menses - Normal range
Lasts less than 7 days
Less than 80mL in total volume
Menorrhagia
Excessive menstrual flow
Menometrorrhagia
Irregular AND heavy menses
STIs we ask about in the history
Herpes simplex Syphillis Gonorrhea Chlamydia HIV PID HPV
Past Medical History - Don’t miss these!
Hypertension Hepatitis Diabetes Cancer Heart disease Thyroid disease
Include duration, severity and therapies!
Surgical history - Detail to remember
Note if surgical procedures were via laparoscopy or laparotomy
Review of systems - What makes us worry about preeclampsia?
Headache
Visual disturbances
Epigastric pain
Facial or hand swelling
Review of systems - Elderly patient considerations
Symptoms suggestive of cardiac disease:
Chest pain Dyspnea Fatigue Weakness Palpitations
Clinical Pearl - What do we look out for in every pregnancy > 20 weeks gestational age?
Preeclampsia
What are we looking for in the breast examination?
Symmetry Skin or nipple retraction with hands on hips Masses (palpation) Nipple discharge Axillary and supraclavicular nodes
Systolic flow murmurs in a pregnant woman
Normal. Increased cardiac output.
Diastolic murmurs in a pregnant woman
Unusual
Grey Turner sign
Discoloration at the flank areas.
May indicate intra-abdominal or retroperitoneal hemorrhage.
Ulcers on the external genitalia may indicate
Herpes simplex
Vulvar carcinoma
Syphillis
Vulvar mass at 5:00 or 7:00 position may suggest
Bartholin gland cyst or abscess
If you see pigmented lesions on the external genitalia
Get a biopsy.
Malignant melanoma is not uncommon in the vulvar region.
Rectal Exam - Nodularity and tenderness in the uterosacral ligament may suggest
Endometriosis
Rhogam - When and to whom?
Administer at 28 weeks gestational age if the mother is Rh (-) in order to prevent isoimmunization.
Administer again at delivery if the baby is, indeed, Rh (+)
Mom tests positive for HBsAg. What do you do?!
At birth, give the newborn Hep B Immune Globulin (HBIG) and Hep B vaccine to prevent neonatal hepatitis.
If mom is not already immune to rubella, why don’t we vaccinate her until immediately postpartum?
It is a live-attenuated vaccine, so can’t be given during pregnancy
Mom tests positive for syphillis while pregnant but she’s allergic to penicillin. What do you do?
Desensitize her, then give penicillin.
What are we looking for with a urine culture or urinalysis?
Asymptomatic bacteriuria.
6 - 8% of pregnancies are complicated by this
Why do many physicians prefer liquid-based media for ectocervical and endocervical sampling in a pap smear?
Provides better cellular sampling
Allows for HPV subtyping
What do we screen the serum for between 16 and 20 weeks gestational age?
Down’s Syndrome
Neural Tube Defects
Also screening for trisomies with serum Pregnancy-Associated Plasma Protein-A (PAPP-A) and βhCG as well as nuchal translucency (NT) has gained popularity at this point.
PAPP-A
Pregnancy-Associated Plasma Protein-A
Found in the serum, used for first-trimester screening for trisomies
βhCG
Beta Human Chorionic Gonadotropin
Used in first trimester screening for trisomies, among many other things we will get to.
NT
Nuchal Translucency
Used in first trimester screening for trisomies
What do we screen for at 26 - 28 weeks gestational age?
Gestational diabetes.
Give a 50g oral glucose load
Assess the serum glucose after 1 hour
If adopting the “culture strategy” for Group B Strep, when are introital cultures obtained?
35 - 37 weeks gestational age
What does quantitative hCG and progesterone level tell us?
Viability of the pregnancy
Possibility for ectopic pregnancy
Menorrhagia due to uterine fibroids - Lab tests to run
CBC Endometrial biopsy (to assess for endometrial cancer) Pap smear (to assess for cervical dysphasia or cancer)
55+ year old woman with an adnexal mass - Labs to run
CA-125
CEA tumor markers
Looking for epithelial ovarian tumors
Sonography - Thickened endometrial stripe in a postmenopausal woman
May indicate malignancy
Sonography - What is the point of a saline infusion into the uterine cavity?
Enhances the ultrasound examination of intrauterine growths, such as polyps
Clinical Pearl - Sonohysterography
Ultrasound examination of the uterus after injecting saline into endometrial cavity
This is done via transcervical catheter
It can help identify endometrial polyps or submucous myomata
Why does the gynecological ultrasound exam usually involve the kidneys as well?
Hydronephrosis may suggest a pelvic process (ureteral obstruction)
IVP
Intravenous Pyelogram
IV dye is used to assess:
Concentrating ability of the kidneys
Patency of the ureters
Integrity of the bladder
Can also detect:
Hydronephrosis
Ureteral stone
Ureteral obstruction
HSG
Hysterosalpingogram
Radiopaque dye is introduced through transcervical cannula, and radiographs are taken.
Useful in detecting:
Intrauterine abnormalities (submucous fibroids or intrauterine adhesions) Patency of fallopian tubes (tubal obstruction or hydrosalpinx)
Clinical Pearl - What is the single most important tool in obtaining a diagnosis?
The history
