Case Files O&G Flashcards
A 48-year-old G3 P3 woman complains of a 2-year history of loss of urine four to five times each day, typically occurring with coughing, sneezing, or lifting; she denies dysuria or the urge to void during these episodes. These events cause her embarrassment and interfere with her daily activities. The patient is otherwise in good health. A urine culture performed 1 month previously was negative. On examination, she is slightly obese. Her blood pressure is 130/80 mm Hg, her heart rate is 80 beats per minute, and her temperature 99°F (37.2°C). The breast examination is normal without masses. Her heart has a regular rate and rhythm without murmurs. The abdominal examination reveals no masses or tenderness. A midstream voided urinalysis is unremarkable.
- What is the most likely diagnosis?
- What physical examination finding is most likely to be present?
- What is the best initial treatment?
Genuine stress urinary incontinence
Hypermobile urethra, cystocele, or loss of
urethrovesical angle.
Kegel exercises and timed voiding.
Case 1
A 55-year-old woman notes constant wetness from her vagina following a total vaginal hysterectomy procedure, which she had undergone 2 months previously. She denies dysuria or urgency to void. The urinanalysis is normal. What is the best method to diagnose the etiology of urinary incontinence?
Dye instillation into bladder
Case 1
A 42-year-old woman with long-standing diabetes mellitus complains of small amounts of constant dribbling of urine loss with coughing or lifting.
What is the most likely diagnosis?
What is the best therapy?
- Overflow Urinary Incontinence (Neurogenic Bladder)
- Intermittent self-catheterization
Case 1
A 39-year-old woman wets her underpants two to three times each day. She feels as though she needs to void, but cannot make it to the restroom in time.
What is the most likely diagnosis?
What is the best therapy?
- Urge Urinary Incontinence
- Oxybutynin (Ditropan, an anticholinergic medication relax overactive detrusor muscle
Case 1
A 35-year-old woman has undergone four vaginal deliveries. She notes urinary loss six to seven times a day concurrently with coughing or sneezing. She denies dysuria or an urge to void. Her urine culture is negative.
What is the most likely diagnosis?
What is the initial therapy?
- Stress urinary incontinence
- Kegel exercises (pelvic floor strengthening)
- urethropexy if Kegel exercises fail
After a 4-hour labor, a 31-year-old G4 P3 woman undergoes an uneventful vaginal delivery of a 7 lb 8 oz infant over an intact perineum. During her labor, she is noted to have mild variable decelerations and accelerations that increase 20 beats per minute (bpm) above the baseline heart rate. At delivery, the male baby has Apgar scores of 8 at 1 minute, and 9 at 5 minute. Slight lengthening of the cord occurs after 28 minute along with a small gush of blood per vagina. As the placenta is being delivered, a shaggy, reddish, bulging mass is noted at the introitus around the placenta.
- What is the most likely diagnosis?
- What is the most likely complication to occur in this patient?
Most likely diagnosis: Uterine inversion.
Most likely complication: Postpartum hemorrhage
List the FOUR signs of placental separation
- Gush of blood
- Lengthening of the cord
- Globular-shaped uterus
- Uterus rising to the anterior abdominal wall
What is the most common complication of inverted uterus
Hemorrhage
What should you do when the placenta does not deliver spontaneously after 30 minute?
Attempt manual extraction
A 49-year-old woman complains of irregular menses over the past 6 months, feelings of inadequacy, vaginal dryness, difficulty sleeping, and episodes of warmth and sweating at night. On examination, her blood pressure is 120/68 mm Hg, heart rate is 90 beats per minute, and temperature is 99°F (37.2°C). Her thyroid gland is normal to palpation. The cardiac and lung examinations are unremarkable. The breasts are symmetric, without masses or discharge. Examination of the external genitalia does not reveal any masses.
- What is the most likely diagnosis?
- What is your next diagnostic step?
-Perimenopausal state
-Serum follicle-stimulating hormone (FSH) and
luteinizing hormone (LH)
What is the indication for hormone replacement therapy in the menopausal woman?
Significant vasomotor symptoms (night sweats, hot flashes, and flushes)
-Use the lowest dose for the shortest duration feasible
How would you counsel women to prevent osteoporosis?
- Weight-bearing exercise
- Calcium
- Vitamin D supplementation
- Estrogen replacement therapy with progesterone if uterus present to prevent endometrial cancer
The Women’s Health Initiative Study raised concerns about the risks regarding continuous estrogen-progestin treatment. What were they? List TWO
Small but significant increase risk of:
- Breast Cancer
- Heart disease
- Pulmonary embolism
- Stroke
The Women’s Health Initiative Study found benefits of women on hormone replacement therapy. List two benefits
- Fewer Fractures
- Lower incidence of colon cancer
You have a patient in septic shock. How would you manage this patient
- ABC’s
- Oxygen
- Monitors-perfusion and organ function (BP cuff, Pulse Ox, ECG leads)
- Intravenous fluids
- Source control-removing cause of infection
- Intravenous broadspectrum antibiotics
What organism is most typically responsible for causing a sunburn-like rash and/or desquamation infections?
Staphylococcus aureus
Despite intravenous isotonic fluid replacement, your patient remains hypotensive. What is your next step?
Vasopressor support such as intravenous infusion of dopamine
An 18-year-old G1 P0 adolescent female, who is pregnant at 7 weeks’ gestation by last menstrual period, complains of a 2-day history of vaginal spotting and lower abdominal pain. She denies a history of sexually transmitted diseases. On examination, her blood pressure (BP) is 130/60 mm Hg, heart rate (HR) is 70 beats per minute, and temperature is 99°F (37.2°C). Her neck is supple and the heart examination is normal. The lungs are clear bilaterally. The abdomen is nontender and no masses are palpated. On pelvic examination, the uterus is 4-week size and nontender. There are no adnexal masses on pelvic examination. The quantitative β-hCG level is 700 mIU/mL and a transvaginal ultrasound reveals an empty uterus and no adnexal masses.
What is your next step in the management of this patient?
Follow up β-hCG in 48 hours
A 35-year-old G5 P4 woman at 39 weeks’ gestation is undergoing a vaginal delivery. She has a history of a previous myomectomy and one prior low-transverse cesarean delivery. She was counseled about the risks, benefit, and alternatives of vaginal birth after cesarean, and elected a trial of labor. She proceeded through a normal labor. The delivery of the baby is uneventful. The placenta does not deliver after 30 minutes, and a manual extraction of the placenta is undertaken. The placenta seems to be firmly adherent to the uterus.
- What is the most likely diagnosis?
- What is your next step in management for this patient?
- Placenta accreta
- Hysterectomy
List 5 risk factors for placenta accreta
- Placenta previa
- Implantation over the lower uterine segment
- Prior cesarean scar or other uterine scar
- Uterine curettage
- Fetal Down syndrome
A 22-year-old nulliparous woman complains of a 2-week history of vaginal discharge and vaginal spotting after intercourse. She denies a history of sexually transmitted diseases and currently does not use any contraceptive agents. Her past medical history is unremarkable. Her last menstrual period began 1 week ago and was normal. On examination, her
blood pressure is 100/60 mm Hg, heart rate 80bpm, and temperature is 37.2°C. The heart and lung examinations are normal. Her abdomen is nontender and without masses. Her pelvic examination shows purulent vaginal discharge, which on Gram stain shows intracellular gram-negative diplococci. Her pregnancy test is negative.
- What is the most likely diagnosis?
- What is the next step in therapy?
- What are the complications of this problem?
- Most likely diagnosis: Gonococcal cervicitis.
- Next step in therapy: Intramuscular ceftriaxone for gonorrhea, and oral azithromycin (or doxycycline) for chlamydial infection.
- Complications of this problem: Salpingitis, which may lead to infertility or increased risk of ectopic pregnancy. Disseminated gonorrhea is also possible.
When a pregnant woman has an open cervical os with uterine cramping and history of passage of tissue, what is her most likely diagnosis? What would be the best therapy option?
- Incomplete abortion
- Uterine curettage
What is the most common cause of first-trimester miscarriage?
Fetal karyotypic abnormality
What are some characteristics of a molar pregnancy?
- Vaginal spotting
- Absence of fetal heart tones
- Size greater than dates
- “Snowstorm” on ultrasonography
What is the age range of perimenopause?
40-51yo (avg 47yo)
47yo female with night sweats, hot flashes, and flushing. She cannot sleep due to these symptoms. How would you treat her?
Hormone replacement therapy: estrogen if no uterus
Estrogen + progesterone if uterus is present
*use lowest effective dose for
List FIVE symptoms of hypoestrogenemia in the perimenopausal woman
- Vasomotor (night sweats, hot flashes, flushing)
- Decreased epithelial thickness
- Vaginal atrophy
- Vaginal dryness
