Case Studies
Am I ready to do office gyn?
Sally is a 23 y/o GoPo complaining of irregular
bleeding
Gyn Hx: sexually active uses condoms most times
PE: 105 lb
Abdomen soft nontender
Pelvic exam: no vaginal bleeding, Cervix is closed
nontender, uterus normal, adenexa neg
Test Results
• Quantative Beta HCG < 1
• Ultrasound normal uterus, endometrium,
and ovaries
What if Ultrasound Shows
• uterus 11x9x8 cm with multiple
leiomyoma about 2-3 cm in diameter,
endometrial thickness 6 mm, normal
ovaries
Sally returns after 3 months on her new birth control
pill still having breakthrough bleeding
Pelvic exam is normal
Test: STD negative
pregnancy test negative
Judy returns for annual exam on Ortho Tricyclen Lo
Social hx: married, monogamous
She is complaining that she had regular periods for a
while but now having breakthrough bleeding for 6
months
Exam: Normal
Differential diagnosis?
Jenny is a 24 year old G1P0, LMP: 6 weeks ago
CC: bleeding like period with severe cramps
PI: +home pregnancy test last week, onset of
menstral like bleeding with severe menstral cramps
6 hours ago
PMH: negative
• Exam shows dilated cervix and tissue at
the os. Next step?
• Exam shows moderate amount of blood
coming from a closed os? Next step?
• Quant = 600. DDX
• Quant = 1800, us = gestational sac. DDx?
• Quant = 1800, us = shows thickened
endometrium. DDx?
Path Report Shows:
• Chorionic villi. DDx?
• No chorionic villi. DDx?
• Hydatidiform mole or molar pregnancy or
molar degeneration. What is the follow
up?
Mary is a 45 y/o G3P3 status post tubal ligation
Menstral formula:
2 weeks/3 days heavy on day 1
PMH: negative
Pelvic exam: Cervix normal, pap done
Uterus 6 weeks size, irregular, firm,
nontender
Ovaries not enlarged, nontender
Guidelines for Endometrial Biopsy
• All women with history of AUB of 2-3 yrs
duration
• All women > 45 yrs old with AUB
• All women who do not respond to
treatment
Endometrial Biopsy Results
• Complex hyperplasia with atypia
• Complex hyperplasia
• Simple hyperplasia
• Proliferative endometrium
• Secretory endometrium
Vicki is a 60 y/o complaining of 3 days of light bleeding 3 weeks
ago
PMH: Illnesses:
diabetes controlled on diet
mild hypertension
Meds: Atenolol
Continuous hormone replacement therapy
Exam: 5’4”, 175 lb
Pelvic:vagina slightly atrophic
cervix stenotic, pap done
uterus NS/NS
adenexa negative
Endometrial thickness
• < 4 mm generally atrophic endometrium
• > 4 mm you can’t rule out cancer
60 yr old menopausal female complaining of
incontinence
PI: leaking urine for several months now worse
PMH: TAH/BSO for benign disease age 45
Lumbar disk fusion 1 years ago
PE: Pelvic – 1st degree cystocoele and 1st degree
rectocoele
• Complaining of urgency, frequency,
nocturia, sudden loss of large amounts of
urine
• Residual urine 10 ml
• Urine culture positive > 100,000 e-coli
• Loss of urine with coughing, sneezing,
laughing, squatting, jumping
• Residual 50 ml and culture negative
• Residual > 200 ml
22 yr old female complaining of amenorrhea for 1 yr
PI: LMP 1 yr ago prior menstral formula 28d/5d
BC: none
Gyn Hx delivered a baby 2 yrs ago
PMH: Schizophrenic on anti-psychotic med
Soc Hx: Occasionally sexually active without condoms
PE: Thin female, no distress
Breasts bilateral milky discharge
Pelvic exam normal
• Prolactin 100 ng/ml., TSH 5.5 uU/ml.,
• Prolactin, TSH normal
On 10/28/97, JP a 33 y/o G2P2 presented with a
cc intermenstral spotting not associated with pain
or activity
Uses ortho cept correctly
Delivered by repeat c/s 8/1/96, started on BCP in hospital
did not return for pp exam.
Exam and pap smear normal
Recommend continue ortho cept and call if bleeding continued
to be a problem
1/2/98 seen in hospital as consult
cc RLQ pain for 2 weeks
No vaginal bleeding, off ortho cept
PMH remarkable for hemoptysis, CXRay
lung nodules
Exam showed enlarged liver,
abdomenal tenderness
normal pelvic exam
CT of abdomen showed free blood, liver
metastasis
CT of head no lesions
Open lung biopsy reveal choriocarcinoma
Diagnosis: metastatic gestational
trophoblastic disease
Transfer to U of I for treatment, patient
subsequently
died from her disease