Step 2 Obstetrics and Gynecology CF-3

CASE 26: A 1 cm breast mass is discovered during a routhine physical examination of a 22yo woman. She has no family history of breast cancer. She denies breast leakage or prior irradiation. On examination, her BP is 100/60. Physical examinations are normal. Palpation of her rt breast reveals a firm, mobile nontender rubbery 1 cm mas in the upper outer quadrant. No adenopathy is noted. The left beast is normal to palpation. Next step? Dx?

Fibrocystic changes versus fibroadenoma?

Clinical approach to breast mass?

34yo complains of unilateral serosanquineous nipple discharge from the breast, expressed from one duct. No mass is palpated.

27yo woman complains of breast pain, which increases wiht menses. The breast has a lumpy bumpy sensation.

47yo has a 1.5cm rt breast mass wiht nipple retraction and skin dimpling over the mass.

18yo asymptomatic 1cm nontender mobile rt breast mass.

CASE 27: 23yo G1P0 at 40 weeks gestation undergoing labor induction with oxytocin for oligohydramnios. She has been at 6cm dilation for 3 hrs. A significant amount of caput is noted on cervical exam. Her uterine contractions are every 2-3 min and palpate firm. Each contraction lasts for 60 sec. The estimated fetal weight is 7.5lb, and the pelvis seems clinically adequate. The fetal heart tones range from 145-150bpm without decelerations. Next step? Dx?

Addequate uterine contractions in active phase?

Dx of arrest of active phase?

3 P'S

The cervix of a 19yo G1P0 at 39 weeks is noted to change from 2 to 3 cm over 4 hrs. Dx?

25yo G2 P1001 at 41 weeks is noted to change her cervix from 6 to 9 cm over 2 hrs. Dx?

30 yo G1P0 at 39 weeks gestation, who does not have an epidural catheter, is completely dilated for 2 hrs at 0 station. Dx?

38 G3P2 at 38 weeks has changed her cervix from 6-8 cm over 3 hrs. Dx?

25yo G1P0 at 39 weeks is in labor. The cervical examination reveals complete dilation and the fetal head at +1 station for 2 hr despite maternal pushing. Which is the most likely etiology for this labor disorder?

CASE 28: 31yo G1P1 presents wiht a 2yr history of infertility. She states that her menses began at 12 years and occurs at 28 day intervals. A biphasic basal body temperature chart is recorded. She denies sexually transmitted diseases, and a hysterosalpingogram shows patent tubes and a normal uterine cavity. Her husband is 34yo and his semen analysis is normal. Etiology?

Five basic factors for evaluation?

Ovulatory, history? test? therapy?

Uterine, history? test? therapy?

Male factor, history? test? therapy?

Tubal, history? test? therapy?

Peritoneal, history? test? therapy?

explain the "ovulation chart"

22 yo G0P0 irregular menses every 30-65 days. Semen analysis is normal. The hysterosalpingogram is normal. Treatment?

26yo G0P0 has regular 28 day menses. Semen analysis is normal. The patient had a postcoital test revealing motile sperm and strechy, watery cervical mucus. She has been treated for chlamydial infection in the past. Etiology for her infertility?

28yo G1P1 complains of painful menses and pain with intercourse. She has menses every month and denies a history of sexually transmitted diseases. Which tests would most likely identify the etiology of the infertility?

34yo infertile woman is noted to have evidence of a blocked fallopian tube by hysterosalpingogram. Best next step for this patient?

CASE 29: 23yo G2P1 29 weeks compains of a 12hr of colicky right lower abdominal pain and nausea and vomiting. Denies vaginal bleeding or leakage of fluid per vagina. She denies diarrhea or eating stale foods. She has a history of an 8cm ovarian cyst but otherwise has been in good health. She denies dysuria or fever and she has had no surgeries. Her BP 100/70, HR 105bpm, RR 12/min, Temp 99F'. On abdominal examination, her bowel sounds are hypoactive. The abdomen is tender in the rt lower quadrant, with involintary guarding. Cervix is closed. Fetal heart tones are in the 140bpm range. Dx? Best treatment for this condition?

Differential diagnosis of abdominal pain in pregnancy?

Appendicitis, time during pregnancy, location associated symptoms, treatment?

Cholecystitis, time during pregnancy, location associated symptoms, treatment?

Torsion, time during pregnancy, location associated symptoms, treatment?

Placental abruption, time during pregnancy, location associated symptoms, treatment?

Ectopic pregnancy, time during pregnancy, location associated symptoms, treatment?

Describe the movement of the appendix in pregnancy as compared with nonpregnant.

Upon performing laparoscopy for a suspected ovarian torsion in an 18yo nulliparous woman, the surgeon sees that the ovarian vascular pedicle has twisted 1 to 1.5 times and that the ovary appears somewhat bluish. Managment?

Which of the following describes the correct anatomic characteristics of the vessels in the infundibular pelvic ligament to the ovary?

18yo G1P0 complains of a 2 month history of colicky right abdominal pain when she eats. It is associated with nausea and emesis. She states the pain radiates to her right shoulder. The patient has a family history of DM. Dx?

CASE 30: 19yo G2 Ab1 at 7 weeks gestation by LMP complains of vaginal spotting. She denies the passage of tissue per vagina, trauma, recent intercourse. Medical history significant for pelvic infection approximately 3yrs ago. She had used oral contraceptives 1 yr prior. Appetite is normal. On examination, BP 100/60, HR 90bpm, temp normal. Abdomen is nontender with normoactive bowel sounds. On pelvic examination, the external genitalia are normal. Cervix is closed and nontender. Uterus is 4 weeks size, and no adnexal tenderness is noted. Quantitative b-HCG is 2300mIU/mL. Transvaginal sonogram reveals an empty uterus and no adnexal masses. Next step? Dx?

Strategy to rule out ectopic pregnancy?

Transvaginal US

b-HCG and Progesterone in ectopic pregnancy.

Methotrexate in ectopic pregnancy.

22yo 8 weeks gestation has vaginal spotting. Her physical examination reveals no adnexal masses. The hCG level is 400ng/mL and transvaginal US shows no pregnancy in the uterus and no adnexal masses. Which of the following is the best next step?

26yo G2P1 7 weeks gestation seen 1 week ago with grampy lower abdominal pain and vaginal spotting. Her hCG level was 1000mIU/mL. Transvaginal US today shows no clear pregnanacy in the uterus and no adnexal masses. Based on the information presented, which of the following can be concluded?

17yo lower abdominal pain and spotting comes to the ER. She has an hCG level of 1000 mIU/mL and a progesterone level of 26ng/mL. Dx?

Primary utility of the transvaginal US in the assesment of an ectopic pregnancy?

29yo complains of syncope. She is 6 weeks pregnant and on examination has diffuse significatn lower abdominal tenderness. Pelvic examination is difficult to accomplish due to guarding. Her hCG level is 400 mIU/mL. and transvaginal US shows no pregnancy in the uterus and no adnexal masses. Best next step?