A 2O-yw-dd GO PO womiI~ wmes to the cace Sliding thai her 1,)51 rnensIn.i1II period 'lIdS 2 l1lOOlh5ago. She prl'Yiouslyhashod.r menses. She became seru.J~ ece e couple 01 monlhs ago and hasl«n using a oontroceptiw diaphJogm i!regul~,Iy. Sncett>ensheh<l5no1eda peaem 01 naU$!!.l with frequent VOfIliting. Also, sht has noti<W a funness in her breasts with iooeased lI'ntk.>rne5s lora leww<'€1:.s. She a\so Compldinsof coostantlyfeeling IMiglled even after she h.J5h,dadequatell~p.GeneralphysM:alexaminationiIUnrMlarimble. ~Mc examinationrl"Veal>ilnontender.ant~Ulerus,'Oweeks'~ze
2_ P",n.,a1I,bonn0'1',tudies(compi ... bioodC(lunl,urinaly>i,.urin<cullure,hloodIYl"',nd olypic.oilUlt;body",reen."'rology,rubdl.igGlit<r,hcpariti.B,urf''''''''';g<n,.idlkccU ><r«n, <"v;eal <uilnres ro' ~on"rrh<. ,od chlamydia, Pap ,me.r). D;son« m"<mal·oemm .lph,.f".lprot<inanJH1Vtesting
1. Nutrition.1 counsoling(",courag< fr.qu<nl.m.ll m •• I",bl."J roo,l~aV(l;d frlod food,) P""uih< 3(1 mg ofei<mentol iron a day and fol .. < 0_4 mg. daj'
Normol p"gnoncy mimics many Dlh.r <ondil;Ono, olim making an .«",,"< din'''l di'gIIo ,is more ch.II'nging 10 \h, p'WitiQ"<r," ~.hCG i'V<'1"redflC for lrophoblosli< villi and
Final diagnosis Norm,lp··so.ncy
eASE 2
History and physical examination A2~r-<lldprimigravidaWOlllMlil1.8~·ge>tationtorTll51olheollice beo:=eol~lblffdinBandminimal""""'abOOrninal(tam;XrtsloroneWy_ >hederri6l1auma.lli!l/Iea.\IOmitini!.anddysuria.Herlilll~imerroursewao; 2 weeI:s ago. She isa!ebrile lIi!h stab~vital signl. Her abdomen is soft and nondisle"dedwilhminimal,upfilpubictendern!$SpeculumeXdmina~onre"leols asrnallamountofd3r,redbtoodinlhevagina_Therervixisdo>ed,~ndno lesions ore seen. Bimanual examination sho",.; a slighlly enlarged,symmelrir no lIl€!lder ulerus.No(ervi(OlmoliontelldelnessisnO!ed,andfl()adne~lmiJSSispalpated.
Lap.ro,omy, If the p.ti<nt i> hrrnodyn .. nkally unstable (to'h)"Ordk ,"d hypot<n<ive) ~;th findingo.ugg<stiveofintnp<rilOnealbWding(abdominalguudingOltdrdloundl,<mefg<ncy b.parotomyton"pth.h<mOflh'g<i>indi,,1<d.
Lapo.roll<Op;<Su.g<ry,Lapa"',",opic""l!"yi.tho,,,,,''''e,,,nfchoi«lnmorc.dvo"«dGO"'~ tho ~·hCG titee is >5,000 mlUlm~. th' ""'OJ'i< on ... it >35 <,n, or c"di.< a<ti"j,y i, ...,n_ If 'h.p"io:nth .. <o"'pleted'hildbo .. ing .... lpiDg<aomy'l>ouldl><pnf"',.,«I.mtili.y-pr< .. ",ing procedure>;ncln<l,. Ii",,, ""pinBO>tomywith UIl"'plUr<d ampuli.oryectop;.;..nd qm<ttt",resro:ionwithprmim.li>thmi<ectopics.
~ l7-ywr-oldgi~romes!otheoutpatiemdin;c~aulI!ollhes"ddenonse\of abdominal pain (increa~ng in intensity). fever.lelh~rgy, ~3kness, and vaginol bleeding,lwod~~lIOsheunde""",masuctiondilititiooand(uretlilgeabDrtiOn procedure for an unwanted 8-weel: pregnanC)'. Before th~ visit, she Ilad no complail1lS,Shedeniesnilu>eaor\'Ol'l1iting,Sheh~hadregularboweifurKtiOl1 VilaI5igm~re:~arure39.s((103.1f),bIoodpres5lJle9ql6OmmHg.pu!se lCKVmin.dIId~3Qlmin_Ongener~examination.hef=itie5.",aid arlddiaphort1io;_lung5"",deorlDausailaticnbil;lleldlly.Puises~ .. ",k,wiIh regular rate and m,mm. Her abdomm is flat, !Cit, lernIe! in lhemid-to lower abdomen.witI1Ktivebowel50uncl~butoogUoll'dingorreboondtendeJflI5S.PeIvic examin<ltionr~lsd6-weel;~le.elQuisiK+;!eoderu!erus.C~aPl"!<lrsd~d witI1i1lhid,mlJ(opurulefl!dischdrge,The'ei5nopalpableadne>:illm~
Hi~oryandphysjcalexamination A»year-okiroolti~\Wmanal:snMeks'gesto-oonbydatecornestolhe emergrocydep.lrtml'!llintherriddleof1ht>nightrompJainingofp.linIessYilgiMi bleeding.She~e~nhour~godfteflrelingblood1JidlingdoYmhertegs_She IIOIed 0 pool of blood on herl:>edlheets,od nightgooTI_ She has minirflill ut ...... ne tightening, SIIe denies recenlSelu~1 inlercourse, She stales that ttee is good ler,1 movement, She has had no prelliltalca~, Her first pregnancy ended \'lim on emergency low Tr~nsvel5e cesarean section ~I term for breedl presentation. She smOKes,padot (igarenesadayand3dmit5toomsional mcaine U5e, Vital signs are;table_Generalexaminationiluoremarialklheulerusissoftandnontender Fundalheightj528un,Fetalheart'alebyDoppIer5ledlo>copeisB~min,BlighI red blood is seen emetgingfrom her iotroitus.
AAhoolagoihep.llientreo:eivedas-ginlril\lenOOSloadingdoseolMgSO,0I'fI2(I rrinlllesfol1owedbyaniniravt'llOlJSinIu5ioool2g/11our.Helurinl'aulputlias been 15 ml over the ",,51 hour. HeT respi,a~ons, wbi(h were 2Wmin, a~ now '/min.CominU()llSfel<llmon~or,hOWl,b.J>efinefelallleartrateorI40Jminwith decreased variability. There are no oaelerations, but also no decelerators
Historyandphysicalexaminalkm A2l).y&Ir-(JJdwomim,gr.Mdil2,nowpardl,isexperiern:ingpo5lp¥1Umbtee<in&Ar.41~ge;latiooshewasadmi.tedl(ltfle""'tl'lrilyU'l~wirhspOnli!neoos ~matureruptureofrrM'mbfanesandinegularcontraaions.lnIrirYenousOX'JlOdn mlusio"wa5iniIiiHed,Afterslowprogressionofl.bo<,lastingrahoo",~ undeJlM'ntanoutlellorcepsdeirveryola4.3OO1lfemaleneonate,Thematemity unilnU~",II,youlllOurpostde!ive.rys1atingthepatientisblee<lingheavilyand is pa>ling doK Herbbod pressure is 80/40 mm Hg. and her pulse il 125/min
Discussion 'I1t.mostcriticalini'iaI"tp.inma""gtmcn'arc"obilizingth<p.tim1'.vital.ignirnden'ur. ing.deq"'''p<otu.ionof.j.aJorg.>n~ The patienI",h;'tory is posilil'< wi,h many rioJ<fl(1or> fOTU1<tfu'''''"y.Ut<rotonic.gt"uandut<rinem'<ioge.",,,...,nlial
Finaldiagnosi5 ro.'p.,-,umh<IDllrth·s<
J8 R*lical
~~':':;':~""'"'~"'.:::O"_'_""'.""."'"" I
I (MgSO, or 1)-.m",ergi(ogcni<.B),and """distended \llel1IS
The POUe<l1 s now 5 em dilated, 10CRtJ effaced -I 51a~Qn Voith uterine con~ioions every 1 10 l minulf$Or1 the~emlilowc.l-tn'momeler. The~er!roni( fetal mon~oru.!dng. usingextemal sonocardilgraphy. show; a bdseiinefetaf hean r.lte of l6IVmin. IIOOtIilf v~riabililv but occa5ion~f f~pid drop:; III lKVmin. Idin8 15 ~lIII5,theo,apil:lyrelurninglobdseiioe.
Part 111: Five Hours Later on the Maternity Unit
Results
Treatment plan
Discussion
mec.lcal 49
USMLESlepl;ObsWtri",G)'IWology
Part IV: Four Hours later on Intravenous Oxytocin in the Maternity Unit
The psient isnow IOcmdilale\l,lrmlleffaced,+2Italiun, Uterineronuactions are six in 10 mnetes erd lostingior60 seconds, and the fetal heart rae i, 90/min
EtrOpic I"W'~~<J' i. di.goo><d i')' Jl.-hCG "" .. dioclW<d in Obmtri"" c- l N>".,.airi!i,i.u>uaUyunil.,<raI.ndrigh,·.tded.I,isma""g«Iby'ursical",n",vaL
• M'nagemenl may be medical (Ieuprolide prefll'{llmeaomy ,hri"~,ge) or "''lIieJl (myomectoml o,~terectomy)
76 mae-teal
CASE 11
Chief complaint
"I h,,,<, lump in m)'I"<"I"
History and physical examination
Results
Further diagnostic plan Re5ults
I r.,i,;on.lb;op,y
treatment plan
mMllcai 77
USMLlStepl;Ol>!;tflri~(iynHDIDIrl
Final diagnosis
78 ~itlcal
Cyn.<l'llngy
CASE 12
Chietcomplaint
History and physical examoenon
Djfferen~al diagnosis
• !rritati",incontin<nce
• Genuin<str",incontin<lKe
treaenentptan
Discussion
~e&lcal 19
USMLEstepl:ObstetrIcs,IGyoecolon'
Gynecalogy
• (,"",dbyjnvolunlaryli%jnblad<lerprN"relromjdjopathj,detrusormnlractioo5thal cannotbevolunlarilysuppressed ·SympIQmsintlud.IO»ol"'ineiniJrgeomoo"lsaficnv.ilhool""rningdayandnight. The most commonsymplOm~urgency_
Historyandphysicalecamination A24~ar-oldG2P2~ncorne:;toyourofficeoompiainingof~wrl:. coarsehilirgrowthonheifice.upper6p.chestandp!Jbic~.Tllehairgrowth h~d a gradu.' onset.t puberty aod is oIlon& duration, She is of Med~e"'nean desrentend states her moIher and sister h.ve ~milar complaints, She bas regul~r lO-daymenstrualcycieswithh€riast menstrual period 2 weeks ago, She denies recent change in her~gh~ lowering of her mice, or incese in acne. On exam;nationshei,65indlestallwilhweightofI3Spounds.Sheha,narmalfemilie b"'''1 d"""klpment ..nh normal female body (ontours, Ph)Sica1 ex.Jmi~atiOll confirmsdarl:terminalhaironilerupperlip,anteriorchest,aodback.Thepilbic hair tli.Jng1e is i1verted with dar!; fIolirs in Ihe mid1ine up 10 tile umbiic_u~ Hff ditori5i1notenIargr>d_Pelvice.r.lminaOOrtisunremad:.1ble.
'nitialdiagnosti(~an
t. S.'"md<h~droepi.nd""'1<ro""."Ir.t< y,"othiooormair.ng<
Th«,i",i, fu,p,im:uyomenormeaar, (J) no m'n'" by ag. 14 AND no sewnda'1' ",,,u,1 d<v<lopm<Il' Or {l) no mm"" by age 16 WITH "'''''"~"..,. "",al d ... lopment.