BOOK
Obstetrics & Gynecology Morning Report: Beyond the Pearls E-Book
Kate V. Meriwether | Joey England | Rajkumar Dasgupta | R. Michelle Koolaee
(2018)
Additional Information
Book Details
Abstract
Concise and easy to read, Obstetrics & Gynecology Morning Report: Beyond the Pearls is a case-based reference that covers the key material included on the USMLE Step 2 and Step 3, as well as the OB-GYN clerkship. Focusing on the practical information you need to know, it teaches how to analyze a clinical vignette in the style of a morning report conference, sharpening your clinical decision-making skills and helping you formulate an evidence-based approach to realistic patient scenarios.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| IFC\r | ES1 | ||
| OBSTETRICS & GYNECOLOGY MORNING REPORT: Beyond the Pearls\r | i | ||
| Copyright | ii | ||
| Dedication | iii | ||
| LIST OF CONTRIBUTORS | iv | ||
| PREFACE | x | ||
| FOREWORD | xi | ||
| CONTENTS | xii | ||
| 1 - A 34-Year-Old Woman With Cervical Dysplasia in Pregnancy\r | 1 | ||
| What is the etiology of cervical cancer? | 1 | ||
| What are the vaccination options for cervical cancer? | 2 | ||
| What are screening recommendations for cervical cancer? | 2 | ||
| What are the recommendations for management of HSIL in the nonpregnant woman? | 2 | ||
| How is a colposcopy performed? | 2 | ||
| What additional considerations are made in pregnancy? | 3 | ||
| How do you counsel this patient about her biopsy results? | 4 | ||
| How should her cervical dysplasia affect her mode of delivery? | 5 | ||
| Does the patient’s cervical dysplasia limit her options for postpartum contraception? | 5 | ||
| What are your options for management? | 5 | ||
| What is the follow-up plan for this patient? | 6 | ||
| Case Summary | 7 | ||
| References | 7 | ||
| 2 - A 23-Year-Old Woman with Hyperemesis Gravidarum\r | 8 | ||
| What questions should be asked when interviewing this patient? | 8 | ||
| What should the physical exam include? | 9 | ||
| What is the differential diagnosis? | 9 | ||
| What is the working diagnosis? | 10 | ||
| What laboratory evaluation and radiologic testing should be performed on this patient? | 10 | ||
| What is the etiology of NVP? | 11 | ||
| What are the risk factors for NVP? | 12 | ||
| How is NVP treated? | 12 | ||
| What is the more severe form of NVP? | 14 | ||
| Case Summary | 14 | ||
| References | 14 | ||
| 3 - A 31-Year-Old Woman With Rash in Pregnancy\r | 16 | ||
| When a pregnant woman develops blisters, what is important to know in her history? | 16 | ||
| What clues in the history point away from a diagnosis of allergic contact dermatitis? | 17 | ||
| What clues in the patient’s history could point toward a diagnosis of an arthropod assault? | 18 | ||
| What clues in this patient’s history might point toward gestational pemphigoid? | 20 | ||
| What treatment options can begin before the patient sees the dermatologist? | 22 | ||
| She is curious if this condition will recur in future pregnancies; what advice can you give her? | 24 | ||
| Case Summary | 24 | ||
| References | 24 | ||
| 4 - A 38-Year-Old Woman with GDM\r | 26 | ||
| What is GDM? | 26 | ||
| What are some relevant questions in your history that might suggest GDM? | 26 | ||
| What risk factors does this patient have for GDM? | 27 | ||
| Who should be screened for GDM? | 27 | ||
| How is GDM diagnosed? | 27 | ||
| What are the risks of untreated GDM? | 31 | ||
| Is antenatal testing indicated with GDM? | 31 | ||
| How should labor and delivery be managed in patients with GDM? | 32 | ||
| How should the patient be managed postpartum? | 32 | ||
| Case Summary | 33 | ||
| Resources | 33 | ||
| References | 33 | ||
| 5 - A 27-Year-Old Woman With Human Immunodeficiency Virus in Pregnancy\r | 34 | ||
| Describe the pertinent history and physical examination for the patient with HIV | 34 | ||
| What laboratory evaluation provides the diagnosis for HIV? | 35 | ||
| What provides the diagnosis for acquired immune deficiency syndrome (AIDS)? | 36 | ||
| What laboratory, imaging studies, and management should be pursued? | 37 | ||
| What is the treatment for HIV during pregnancy? | 37 | ||
| For decreasing CD4 counts, what is the appropriate prophylaxis? | 37 | ||
| How do you counsel the patient postpartum? | 38 | ||
| Case Summary | 38 | ||
| References | 39 | ||
| 6 - A 30-Year-Old Woman With Gestational Trophoblastic Disease\r | 40 | ||
| What is the initial differential diagnosis for the patient? | 40 | ||
| What laboratory, imaging studies, and management should be pursued? | 41 | ||
| What is your diagnosis? | 41 | ||
| Case Summary | 43 | ||
| References | 44 | ||
| 7 - A 28-Year-Old Woman Presenting With Symptoms of Depression in the Postpartum Period\r | 45 | ||
| Why is it important to ask about and discuss emotional health in postpartum women? | 45 | ||
| Is it baby blues, depression, or psychosis? | 45 | ||
| What are additional questions you need answered at this point? | 47 | ||
| What immediate interaction and treatment should you undertake? | 48 | ||
| What referral and long-term treatment is appropriate? | 49 | ||
| Case Summary | 50 | ||
| References | 50 | ||
| 8 - A 25-Year-Old Woman With Pica in Pregnancy\r | 51 | ||
| How does this information help you form a differential diagnosis? | 52 | ||
| What are the concerns that arise with the consumption of soils or “magnesia”? | 52 | ||
| Is consuming so much ice of concern? | 54 | ||
| How do you approach treating the underlying iron deficiency? | 55 | ||
| How do you approach addressing the actual pica substances? | 56 | ||
| How do you approach her long-term care? | 57 | ||
| Case Summary | 57 | ||
| References | 58 | ||
| 9 - A 27-Year-Old Woman With Opiate Dependence in Pregnancy\r | 59 | ||
| Why is it important to screen for opioid abuse in pregnancy? | 59 | ||
| What is a validated method to screen for substance abuse in pregnancy? | 59 | ||
| Based on the history and physical exam for this patient, what is her COWS score? | 62 | ||
| What are the goals of treatment for opioid dependence in pregnancy? | 62 | ||
| What is NAS? | 63 | ||
| What additional testing should you perform prior to initiation of methadone therapy? | 64 | ||
| How should methadone opioid replacement therapy be initiated? | 64 | ||
| What additional care will your patient need throughout her pregnancy? | 64 | ||
| Case Summary | 65 | ||
| References | 65 | ||
| 10 - A 29-Year-Old G1P0 Woman With Hypothyroidism in Pregnancy\r | 67 | ||
| What important questions should be asked to rule out other diagnoses? | 67 | ||
| What is your differential diagnosis at this point? | 67 | ||
| Does the thyroid exam have to be abnormal for thyroid disease? | 68 | ||
| What if a palpable nodule was noted on her thyroid exam? | 68 | ||
| What changes in the thyroid occur in pregnancy? | 69 | ||
| How important is treatment for overt hypothyroidism in pregnancy? | 70 | ||
| What can happen if overt hypothyroidism is not treated in pregnancy? | 70 | ||
| How would you approach treatment? | 70 | ||
| How do you adjust medication during pregnancy? | 70 | ||
| What do you do if she experiencing symptoms of overtreatment? | 71 | ||
| What nutritional requirements are there in pregnancy related to the thyroid? | 71 | ||
| What is the patient’s prognosis? | 71 | ||
| Case Summary | 72 | ||
| References | 73 | ||
| 11 - A 30-Year-Old Woman Undergoes Carrier Screening\r | 74 | ||
| When is the optimal time to discuss the reported family history? | 74 | ||
| What genetic testing is typically available in the preconception period? | 74 | ||
| What is CF? | 74 | ||
| What is this patient’s risk to be a carrier and have a child with CF? | 75 | ||
| What testing should be offered to this patient? | 76 | ||
| Should you offer carrier screening for additional conditions? | 77 | ||
| Based on these results, what is this patient’s risk of having an affected child with CF? | 78 | ||
| What CF carrier screening, genotyping, or sequencing would you offer to the partner? | 78 | ||
| What is fragile X syndrome? | 79 | ||
| Should you offer to test the patient’s partner to see if he is a carrier for fragile X syndrome? | 79 | ||
| What does it mean to be an intermediate carrier for fragile X? | 80 | ||
| Is testing for fragile X syndrome recommended at delivery? | 80 | ||
| What is the most appropriate next step? | 81 | ||
| Should you recommend that they do not attempt a pregnancy? | 81 | ||
| Case Summary | 81 | ||
| References | 82 | ||
| 12 - A 36-Year-Old Woman With | 83 | ||
| Why is it important to ask about headache in pregnancy? | 83 | ||
| In addition to her headache, what other information should be gathered from this patient? | 83 | ||
| Are there any fetal considerations that need to be evaluated? | 84 | ||
| What is your diagnosis at this time, and how would you manage her? | 85 | ||
| Are there any special considerations for her postpartum care? | 86 | ||
| What does the patient need to do at home, and can this happen again in a future pregnancy? | 86 | ||
| Case Summary | 87 | ||
| References\r | 88 | ||
| 13 - A 20-Year-Old Woman With Preterm Premature Rupture of Membranes\r | 89 | ||
| What is the differential diagnosis during pregnancy for suspected vaginal loss of fluid? | 89 | ||
| What is the next step in evaluating this patient? | 89 | ||
| What is the appropriate laboratory and imaging evaluation? | 90 | ||
| What is your diagnosis? | 90 | ||
| What are the etiology and risk factors for PPROM? | 91 | ||
| How do you counsel the patient regarding this diagnosis? | 91 | ||
| What is the next step in management? | 91 | ||
| Describe the management of labor, delivery, and postpartum care for patients with PPROM | 92 | ||
| How do you counsel the patient regarding future pregnancy? | 92 | ||
| Case Summary | 93 | ||
| Acts of Grace Foundation | 94 | ||
| References | 94 | ||
| 14 - A 36-Year-Old Woman at 33 Weeks’ Gestation With Bleeding\r | 95 | ||
| How does this information help you narrow your differential diagnosis? | 95 | ||
| How do you assess a patient like this in triage? | 96 | ||
| What laboratory values or imaging should you obtain? | 96 | ||
| What other complications can arise from a placenta previa? | 97 | ||
| What are the classifications of placenta previa? | 97 | ||
| What other life-threatening causes must be considered? | 98 | ||
| Case Summary | 100 | ||
| References | 100 | ||
| 15 - A 36-Year-Old Woman With Placental Abruption\r | 101 | ||
| What lab evaluation is necessary? | 101 | ||
| What imaging would you like to perform for this patient? | 102 | ||
| What is your next step in management? | 105 | ||
| How do you diagnose disseminated intravascular coagulation? | 105 | ||
| What measures do you need to take to treat her DIC? | 106 | ||
| Case Summary | 107 | ||
| References | 107 | ||
| 16 - A 35-Year-Old Woman With Lower Extremity Swelling\r | 108 | ||
| What are important questions to ask women in the puerperium period with leg swelling? | 108 | ||
| What clues in the history and exam will help you to narrow your differential diagnosis? | 109 | ||
| What further studies will you order? | 109 | ||
| What are the treatment options? | 111 | ||
| What further workup would you order? | 112 | ||
| What would be your next step of management? | 112 | ||
| Case Summary | 114 | ||
| References | 114 | ||
| 17 - A 31-Year-Old Woman Admitted for Induction of Labor\r | 115 | ||
| What is induction of labor? | 115 | ||
| What are the reasons for inducing labor in a pregnant woman? | 115 | ||
| What are the contraindications to induction of labor? | 115 | ||
| How can the likelihood of a successful induction be determined? | 116 | ||
| What is cervical ripening, and how can it be performed? | 117 | ||
| What are the risks associated with cervical ripening and induction of labor? | 117 | ||
| What are some important criteria to consider (and document) before labor is induced? | 120 | ||
| How should this patient’s tachysystole and abnormal fetal heart rate be managed? | 120 | ||
| How is a failed induction diagnosed? | 121 | ||
| Case Summary | 121 | ||
| References | 122 | ||
| 18 - A 35-Year-Old Pregnant Woman With Abdominal Pain\r | 123 | ||
| What are the imperative questions to ask in the patient who presents with abdominal pain? | 123 | ||
| How does the clinical picture develop in a patient with appendicitis? | 123 | ||
| What should be considered in your differential diagnosis? | 124 | ||
| What laboratory changes are associated with appendicitis? | 126 | ||
| What imaging studies are useful in diagnosing appendicitis? | 126 | ||
| Diagnosing acute appendicitis in a pregnant patient | 128 | ||
| What is the treatment of choice for a pregnant female with appendicitis? | 128 | ||
| Case Summary | 129 | ||
| References | 129 | ||
| 19 - A 32-Year-Old Woman With Severe Postpartum Headache\r | 131 | ||
| What is the first step in evaluating the patient with a postpartum headache? | 131 | ||
| What are the diagnostic criteria by the International Headache Society? | 131 | ||
| Why is it important to elicit a history of headache? | 132 | ||
| How does this information help you form a differential diagnosis? | 132 | ||
| What is the anatomy of the spinal tract? | 133 | ||
| What other types of headaches have to be considered? | 133 | ||
| What is the pathophysiology of PDPH? | 135 | ||
| How do you treat this patient who complains of severe headache? | 135 | ||
| What is an EBP, and how is it performed? | 136 | ||
| How does EBP work? | 136 | ||
| What are the risks and benefits of an EBP? | 136 | ||
| What is your differential diagnosis at this point? | 136 | ||
| What would you do if she returned in a few days with a recurrence of the headache? | 137 | ||
| Case Summary | 137 | ||
| References | 137 | ||
| 20 - A 25-Year-Old Woman With Obesity in Pregnancy\r | 138 | ||
| On presentation to prenatal care, what is the first assessment? | 138 | ||
| What are the goals during her first prenatal visit? | 139 | ||
| What are complications of obesity during pregnancy? | 139 | ||
| What are the recommendations for weight gain during pregnancy in obese women? | 140 | ||
| For patients with obesity, what type of skin incision is preferred during a cesarean delivery? | 140 | ||
| Are there any long-term implications of obesity on the women’s health? | 140 | ||
| What has been the impact of bariatric surgery on the health of a woman of reproductive age? | 141 | ||
| What is bariatric surgery? What are the types and their risk and benefit profiles? | 141 | ||
| Case Summary | 142 | ||
| References | 142 | ||
| 21 - A 33-year-Old Woman With Postpartum Vaginal Edema\r | 144 | ||
| What is your differential diagnosis? | 144 | ||
| What is the initial management? | 145 | ||
| How would you manage the patient now? | 146 | ||
| Case Summary | 148 | ||
| References | 148 | ||
| 22 - A 16-Year-Old Girl With Diabetic Ketoacidosis in Pregnancy\r | 149 | ||
| What is most likely causing this patient’s lethargy? | 149 | ||
| What other important questions or findings will help in our differential? | 149 | ||
| With the information provided, what is the likely diagnosis? | 150 | ||
| What is the clinical presentation of DKA? | 151 | ||
| What are the precipitating factors for the development of DKA? | 152 | ||
| 23 - A 38-Year-Old Woman With Abnormal Quad Screen\r | 157 | ||
| What is prenatal genetic screening? What are its objectives? | 157 | ||
| Compare the various genetic screening methods during pregnancy | 157 | ||
| What are integrated, sequential, and contingent screenings? | 158 | ||
| What is the management plan for the patient? | 158 | ||
| What are the risk factors for Down syndrome in the fetus? | 161 | ||
| What is the significance of an increased NT finding in the first trimester? | 161 | ||
| What is a cystic hygroma? | 161 | ||
| With its high sensitivity and specificity, why can’t NIPT replace invasive diagnostic tests? | 162 | ||
| How does multifetal gestation affect the screening test’s performance? | 162 | ||
| Case Summary | 163 | ||
| References | 163 | ||
| 24 - A 17-Year-Old Woman With a History of Sickle-Cell Disease Presenting With Bone Pain\r | 164 | ||
| What clues in the history and physical point to the diagnosis of SCD crisis? | 165 | ||
| How would you treat this patient? | 165 | ||
| How should you counsel the patient’s family? | 166 | ||
| Will the patient get a blood transfusion? | 167 | ||
| How do we manage SCD pain? | 168 | ||
| Will the patient require a cesarean delivery? | 168 | ||
| What are the postpartum recommendations for patients with SCD? | 168 | ||
| What type of contraception can be utilized in patients with SCD? | 168 | ||
| Case Summary | 169 | ||
| References | 169 | ||
| 25 - A 28-Year-Old Woman With Valvular Heart Disease in Pregnancy\r | 170 | ||
| What is the differential diagnosis of a systolic murmur? | 171 | ||
| What cardiac exam findings will be altered during pregnancy? | 171 | ||
| Do heart murmurs during pregnancy require a workup? | 171 | ||
| What workup should be performed to evaluate a concerning heart murmur in pregnancy? | 172 | ||
| How common is aortic stenosis in pregnancy, and what are the common causes? | 172 | ||
| Should you be concerned about aortic stenosis in pregnancy? | 172 | ||
| How can pregnancy outcomes with aortic stenosis be predicted? | 172 | ||
| What workup should be performed for a pregnant patient with aortic stenosis? | 172 | ||
| What cardiac testing will be altered in pregnancy? | 173 | ||
| What is the familial inheritance risk of a bicuspid aortic valve? | 173 | ||
| How should a pregnant patient with aortic stenosis be managed during pregnancy? | 173 | ||
| Is surgical repair of aortic stenosis recommended during pregnancy? | 173 | ||
| How should women with aortic stenosis be delivered? | 174 | ||
| What is the role of a preconceptional counseling visit in women with valvular heart disease? | 174 | ||
| How should mechanical valves be monitored during pregnancy? | 175 | ||
| What anticoagulant should be used in pregnant women with prosthetic valves? | 175 | ||
| How should other valvular diseases in pregnancy be managed? | 176 | ||
| Case Summary | 178 | ||
| References | 178 | ||
| 26 - A 25-Year-Old Woman Undergoes Noninvasive Aneuploidy Screening\r | 179 | ||
| What is noninvasive aneuploidy screening? | 179 | ||
| What facts and questions do you include in your counseling session? | 180 | ||
| What is the significance of these results? | 180 | ||
| What additional testing can be offered to diagnose or rule out Down syndrome? | 180 | ||
| Case Summary | 183 | ||
| References | 183 | ||
| 27 - A 27-Year-Old Woman With Vaginal Bleeding in Pregnancy\r | 184 | ||
| Why is it important to ask about vaginal bleeding in pregnant women? | 184 | ||
| What are the risk factors for this finding? What are the conditions associated with it? | 184 | ||
| What is your differential diagnosis? | 185 | ||
| Case Summary | 189 | ||
| References | 189 | ||
| 28 - A 27-Year-Old Woman With History of Asthma\r | 190 | ||
| What is asthma and its clinical presentation? | 190 | ||
| How is asthma diagnosed? | 191 | ||
| How is asthma treated? | 192 | ||
| What is the significance of asthma classification and approach to management? | 193 | ||
| What is the normal physiology of the respiratory system during pregnancy? | 195 | ||
| What is the effect of pregnancy on asthma? | 196 | ||
| What is the effect of asthma on pregnancy? | 196 | ||
| How does management differ for the pregnant patient with asthma? | 197 | ||
| What is status asthmaticus? | 197 | ||
| What is the optimal ventilator strategy for an acute asthma exacerbation? | 198 | ||
| Case Summary | 199 | ||
| References | 200 | ||
| 29 - A 34-Year-Old Woman With Sleep Disturbance During Pregnancy\r | 201 | ||
| Are there physiologic reasons that OSA would be worse during pregnancy? | 202 | ||
| What are the testing options to diagnose sleep apnea? | 204 | ||
| What are the health risks associated with untreated OSA? | 204 | ||
| Are there any additional potential risks of untreated OSA to the mother that should be consideredin a patient who is pregnant?\r | 204 | ||
| Are there any potential risks of untreated OSA to the fetus? | 205 | ||
| What are the treatment options for OSA? Are there any specific recommendations for treatmentduring pregnancy?\r | 205 | ||
| Are there specific instructions you would give to this woman regarding her delivery and postpartum recovery with regard to her OSA?\r | 206 | ||
| Will OSA that was diagnosed during pregnancy “resolve” after pregnancy is over? | 206 | ||
| Case Summary | 207 | ||
| References | 207 | ||
| 30 - A 25-Year-Old Woman in Her Third Trimester of Pregnancy\r | 208 | ||
| How does a prior history of SLE nephritis impact pregnancy? | 208 | ||
| What does the specific history of class IV nephritis mean for her pregnancy? | 209 | ||
| When is it safe for patients with SLE to become pregnant? | 210 | ||
| When should referral to a maternal–fetal medicine (MFM) specialist be considered? | 210 | ||
| How do you interpret her autoantibody profile as it relates to her pregnancy? | 210 | ||
| What is neonatal lupus? | 211 | ||
| What causes congenital heart block to occur? | 212 | ||
| What is the risk of her child developing cardiac neonatal lupus? | 213 | ||
| How does her historical treatment course impact her current pregnancy? | 213 | ||
| Are her current medications safe? | 214 | ||
| In a patient with a history of lupus nephritis, what specific physical exam findings should you look for?\r | 214 | ||
| What is your differential diagnosis based on the laboratory testing? | 215 | ||
| On inpatient admission, the primary team asks whether additional labs are warranted. What labs should be recommended and why?\r | 215 | ||
| What other antibodies would be useful to evaluate this patient? | 216 | ||
| How do you interpret this new information and additional labs from Table 30.8 and Figs. 30.5 and 30.6?\r | 216 | ||
| When would a repeat renal biopsy be indicated? | 218 | ||
| What are some other management considerations in patients with lupus nephritis in pregnancy?\r | 220 | ||
| Case Summary | 220 | ||
| References | 221 | ||
| 31 - A 29-Year-Old Woman With Systemic Lupus Erythematosus Planning Pregnancy\r | 222 | ||
| How does SLE affect fertility and pregnancy? | 223 | ||
| Does this patient have active lupus? If so, how can you tell? | 223 | ||
| What immunosuppressive medications are safe to be given during pregnancy? | 224 | ||
| What immunosuppressive medications are safe to be given during pregnancy?\r | 224 | ||
| How should her mild arthritic flare be treated now that she is pregnant? | 226 | ||
| What medications should be avoided at this time for treatment of her arthritis? | 226 | ||
| Is it advisable for this patient to breastfeed? | 227 | ||
| Case Summary | 228 | ||
| References | 228 | ||
| 32 - A 29-Year-Old Woman With Shortness of Breath\r | 230 | ||
| What is the differential diagnosis of SOB in pregnancy? | 230 | ||
| How does heart failure present on physical exam? | 231 | ||
| What is pulmonary hypertension? | 231 | ||
| What is the best screening test for pulmonary hypertension? | 233 | ||
| What is the most specific test for pulmonary hypertension? | 235 | ||
| What is the pathogenesis of PAH? | 235 | ||
| What are targeted therapies for PAH? | 237 | ||
| How does pregnancy impact PAH? | 239 | ||
| Case Summary | 240 | ||
| References | 240 | ||
| 33 - A 42-Year-Old With Heavy Vaginal Bleeding\r | 241 | ||
| What are the next steps in evaluating this patient? | 241 | ||
| What is the definition of abnormal menstrual bleeding, and what are the causes? | 242 | ||
| What is the best imaging test to evaluate this patient’s abnormal physical exam? | 242 | ||
| What is the diagnosis? How do you counsel the patient about the ultrasound? | 242 | ||
| What are fibroids, and how are they related to bleeding and symptoms? | 242 | ||
| How are fibroids related to hormones? | 243 | ||
| What are the next steps in managing this patient’s bleeding and acute anemia? | 243 | ||
| Case Summary | 245 | ||
| References | 245 | ||
| 34 - A 38-Year-Old Woman With Acute Pelvic Pain\r | 246 | ||
| What is your initial differential diagnosis? | 246 | ||
| Why is it important to consider the age of the patient? | 246 | ||
| What other risk factors should you ask about in the history? | 247 | ||
| What negative physical exam findings are important in this case? | 247 | ||
| Which laboratory test should be ordered for this patient? | 248 | ||
| What type of imaging test should be ordered for this patient’s evaluation? | 248 | ||
| Based upon this information, what is the most likely diagnosis in this patient? | 250 | ||
| How are adnexal masses categorized? | 250 | ||
| Case Summary | 251 | ||
| References | 251 | ||
| 35 - A 17-Year-Old Girl With Recent Onset of Pelvic Pain\r | 253 | ||
| What are common causes of pelvic pain in a young female? | 253 | ||
| What should be done to evaluate this patient? | 253 | ||
| What is pelvic inflammatory disease? | 254 | ||
| How does PID present? What are the risks of not recognizing PID? | 254 | ||
| What history is needed when PID is suspected, and what are risk factors for PID? | 254 | ||
| What makes a patient a candidate for empiric treatment of PID? | 256 | ||
| How can the patient reduce her risk for recurrent PID? How does this affect her future fertility?\r | 256 | ||
| What contraception is safe for a woman with PID? | 256 | ||
| Case Summary | 258 | ||
| References | 258 | ||
| 36 - A 28-Year-Old Woman With Abdominal Pain and Vaginal Bleeding\r | 259 | ||
| What are your differential diagnoses for this patient? | 259 | ||
| What is your next step in the evaluation of this patient? | 259 | ||
| Based on these findings, what diagnoses are possible or likely? | 260 | ||
| What physical exam findings would be concerning for an ectopic pregnancy? | 260 | ||
| What would be your concerns about observing this patient further? | 262 | ||
| Is medical management an option for this patient? | 262 | ||
| What is the patient’s diagnosis? | 263 | ||
| How would you counsel a patient with one former ectopic pregnancy and unilateral salpingectomy about future pregnancy?\r | 263 | ||
| Case Summary | 264 | ||
| References | 264 | ||
| 37 - A 19-Year-Old With Postoperative Fever and Lower Abdominal Pain\r | 265 | ||
| What is the differential diagnosis for this patient? | 265 | ||
| What are the next steps in the patient’s evaluation? | 266 | ||
| What is the most likely cause of this patient’s symptoms? | 267 | ||
| What factors lead to increased risk for postabortal endometritis? | 267 | ||
| Could this postabortal endometritis have been prevented? | 267 | ||
| How is postabortal endometritis treated? | 268 | ||
| When should she follow up with her provider? | 268 | ||
| Why is it important to treat postabortal endometritis? | 268 | ||
| Could this patient have had postabortal placement of an intrauterine device (IUD)? | 268 | ||
| Case Summary | 269 | ||
| References | 269 | ||
| 38 - A 34-Year-Old Woman With Postoperative Flank Pain\r | 270 | ||
| What is your differential diagnosis for this patient? | 270 | ||
| How do you classify the different types of urinary incontinence? | 271 | ||
| What is the most likely cause of the patient’s urinary incontinence? | 272 | ||
| What test can you do in the office to specifically evaluate this patient for a fistula? | 272 | ||
| What was the sequence of events that led to the formation of this patient’s fistula? | 272 | ||
| What patient and surgical factors lead to an increased risk of fistula formation? | 273 | ||
| What other imaging would be merited on suspicion of a vesico-vaginal or uretero-vaginal fistula?\r | 273 | ||
| How do you approach treatment of uretero-vaginal fistula? | 273 | ||
| How do you follow this patient after discharge? | 274 | ||
| Case Summary | 275 | ||
| References | 275 | ||
| 39 - A 35-Year-Old Woman With an Abnormal Pap Smear\r | 276 | ||
| What are the risk factors for an abnormal Pap smear? | 276 | ||
| How do providers manage abnormal Pap smears? | 277 | ||
| How would you describe a colposcopy experience to a patient? | 278 | ||
| How would you prepare yourself, the examiner, to perform a colposcopy? | 278 | ||
| What is the transformation zone (TZ), and what is its role in colposcopy? | 278 | ||
| How do solutions applied to the cervix highlight lesions or dysplasia on colposcopy? | 278 | ||
| What if no lesions are seen on the colposcopic view of the cervix? | 279 | ||
| What descriptors are used to describe colposcopic lesions, and what is most concerning? | 279 | ||
| How is a cervical biopsy performed? | 279 | ||
| What different results might be seen on cervical biopsy? | 279 | ||
| What types of treatment are available? | 280 | ||
| Which types of dysplasia should be treated? | 280 | ||
| Case Summary | 281 | ||
| References | 281 | ||
| 40 - A 28-Year-Old Woman With a History of Pulmonary Embolism Who Desires Contraception\r | 282 | ||
| What are the risk factors for venous thromboembolism (VTE)? | 282 | ||
| What tests should be ordered to evaluate for familial thrombophilic syndrome? | 282 | ||
| How should this patient be counseled regarding contraception recommendations? | 283 | ||
| What are the recommendations for a family history of VTE? | 283 | ||
| What should you tell the patient about hormone-containing methods? | 283 | ||
| What other reliable, progestin-only options are available for this patient? | 284 | ||
| What recommendations should be given to patients with thrombophilias and contraceptive management in the perioperative period? | 285 | ||
| Case Summary | 286 | ||
| References | 286 | ||
| 41 - A 56-Year-Old Woman With Menopausal Symptoms\r | 287 | ||
| What history is necessary in a patient with these symptoms? | 287 | ||
| How is menopause defined, and what are the associated symptoms? | 287 | ||
| What are the physical exam findings in a postmenopausal patient? | 288 | ||
| What laboratory evaluation is indicated in a patient with menopausal symptoms? | 288 | ||
| What is the treatment of menopause, and when should it initiated? | 288 | ||
| When is hormone replacement therapy contraindicated? | 289 | ||
| What are alternatives to HRT for postmenopausal symptoms? | 289 | ||
| Are there advantages to HRT other than symptom control? | 290 | ||
| When should the patient consider stopping her estrogen? | 290 | ||
| Case Summary | 291 | ||
| References | 291 | ||
| 42 - A 22-Year-Old Woman With Painful Menses\r | 292 | ||
| What is your differential diagnosis for this patient? | 292 | ||
| What factors of the history can differentiate these three diagnoses on the differential? | 292 | ||
| What types of laboratory testing or imaging studies would be useful for this patient? | 293 | ||
| How do you next counsel your patient? | 293 | ||
| What is the next step in management? | 294 | ||
| What surgical options should you discuss with her? | 295 | ||
| What is long-term follow-up for this patient? | 295 | ||
| Case Summary | 296 | ||
| For Further Reading | 296 | ||
| 43 - A 26-Year-Old Woman With Irregular Menses\r | 297 | ||
| What additional information would you want to know from the patient? | 297 | ||
| What is the differential diagnosis for irregular menstrual bleeding? | 297 | ||
| What should you look for in the physical exam? | 297 | ||
| What is the pathophysiology of hirsutism, and what are some common causes? | 298 | ||
| How would you make a diagnosis of PCOS? | 299 | ||
| What comorbidities are associated with PCOS, and how can you screen for them? | 299 | ||
| What PCOS therapies are available to patients who do not currently desire pregnancy? | 300 | ||
| How would you manage hirsutism in a woman with PCOS? | 300 | ||
| What therapies are available for PCOS patients who currently desire pregnancy? | 301 | ||
| What are some important recommendations that you want to review with her? | 301 | ||
| Case Summary | 302 | ||
| References | 302 | ||
| 44 - A 25-Year-Old With Recurrent Pregnancy Loss\r | 303 | ||
| What additional information do you want from this patient? | 303 | ||
| What would be your working diagnosis based on the information that you have on hand? | 304 | ||
| What are common causes of RPL? | 304 | ||
| What testing would you recommend for this patient for her RPL? | 305 | ||
| What do you recommend next? | 305 | ||
| How would you advise her on trying to get pregnant again? | 305 | ||
| Case Summary | 307 | ||
| References | 308 | ||
| 45 - A 17-Year-Old Girl With Absent Menses\r | 309 | ||
| What other questions do you want to ask this patient? | 309 | ||
| How should one approach the diagnosis in primary amenorrhea? | 309 | ||
| What would be the most likely cause of amenorrhea in our patient? | 310 | ||
| What are the physical exam findings to look for when evaluating primary amenorrhea? | 310 | ||
| What labs should be part of her initial workup? | 311 | ||
| What additional workup would you like to order for this patient? | 311 | ||
| What physical exam findings are commonly seen in Turner syndrome? | 311 | ||
| What treatment options are available for her? | 313 | ||
| How would you counsel this patient about attempting pregnancy in the future? | 313 | ||
| Case Summary | 314 | ||
| References\r | 314 | ||
| 46 - A 33-Year-Old Woman With Infertility and Endometriosis\r | 315 | ||
| What additional questions would you want to ask this patient? | 315 | ||
| What would be your working diagnosis based on this information? | 316 | ||
| What are common causes of infertility? | 316 | ||
| What testing would you recommend to this patient? | 317 | ||
| What would you recommend for this patient? | 318 | ||
| What would you discuss next with this patient? | 318 | ||
| What do you recommend next for this patient? | 318 | ||
| Case Summary | 319 | ||
| References | 319 | ||
| 47 - A 22-Year-Old Woman With Amenorrhea\r | 321 | ||
| What is the difference between primary and secondary amenorrhea? | 321 | ||
| How is galactorrhea related to hyperprolactinemia? | 321 | ||
| What medications can cause amenorrhea? | 322 | ||
| What are the next steps in evaluation? | 322 | ||
| What are causes of hyperprolactinemia? | 323 | ||
| What if the patient is taking a medication that may elevate her prolactin? | 323 | ||
| What are secretory or pituitary tumor causes of hyperprolactinemia? | 323 | ||
| What is the next step in management? | 324 | ||
| How long should the patient continue her dopamine agonist? | 324 | ||
| What are contraindications to dopamine agonist therapy? | 324 | ||
| How should women be counseled about prepregnancy planning? | 324 | ||
| How are prolactinomas monitored during pregnancy? | 324 | ||
| How are growing, symptomatic prolactinomas treated during pregnancy? | 325 | ||
| Case Summary | 326 | ||
| References | 326 | ||
| 48 - A 3-Year-Old Girl With Vaginal Discharge\r | 327 | ||
| How is the prepubertal genital tract different from older pubertal females? | 327 | ||
| What is the differential diagnosis of vulvovaginal symptoms in a prepubertal child? | 328 | ||
| Following a thorough history, how will you perform a physical exam? | 328 | ||
| What tests should you obtain? | 329 | ||
| How should the foreign body found on physical exam be removed? | 330 | ||
| How would the evaluation change if the parents reported continued vaginal bleeding and no foreign object was found in the vagina?\r | 330 | ||
| What after-care information should be provided to the patient’s parents? | 331 | ||
| Case Summary | 331 | ||
| References | 331 | ||
| 49 - A 15-Year-Old Concerned About Not Having Her Period\r | 332 | ||
| When should delayed menarche be evaluated? | 332 | ||
| What is the most common cause of primary amenorrhea? | 332 | ||
| What is the differential diagnosis in this case? | 332 | ||
| What is the next step in evaluation? | 334 | ||
| What is this patient’s diagnosis, and what is the etiology? | 334 | ||
| What is the recommended treatment for this patient? | 334 | ||
| What are this patient’s fertility options? | 335 | ||
| What if the patient had no pubic hair but a short (2 cm) vagina? What is the most likely diagnosis in this scenario?\r | 335 | ||
| What is the pathophysiology of CAIS and the associated karyotype? | 335 | ||
| How do you counsel an adolescent with MRKH about sexuality? | 336 | ||
| Case Summary | 336 | ||
| References | 337 | ||
| 50 - A 14-Year-Old Girl With Heavy Menstrual Bleeding Since Menarche\r | 338 | ||
| What additional history would be helpful to assess this patient? | 338 | ||
| What is in the differential diagnosis of abnormal uterine bleeding in an adolescent? | 339 | ||
| Should this patient be evaluated for a bleeding disorder? | 340 | ||
| How is iron deficiency anemia treated? | 341 | ||
| What is the pathophysiology of von Willebrand disease? | 341 | ||
| How should the patient’s heavy menses be treated? | 342 | ||
| What are the risks and benefits of combined OCPs? | 342 | ||
| How can acute, heavy vaginal bleeding be managed in an adolescent patient? | 342 | ||
| Case Summary | 343 | ||
| References | 343 | ||
| 51 - An 11-Year-Old With Gender Identity Concerns\r | 344 | ||
| What is gender dysphoria? | 344 | ||
| What are the initial steps in caring for this patient? | 344 | ||
| How does the onset of puberty affect the management of this patient? | 345 | ||
| Is any additional history needed for this patient? | 345 | ||
| What medical treatment options are available to transgender patients? | 346 | ||
| Does hormonal treatment have an effect on future fertility? What are this patient’s options? | 347 | ||
| What surgical options are available to transgender patients? | 347 | ||
| What long-term health considerations need to be discussed specific to transgender patients? | 347 | ||
| Case Summary | 349 | ||
| References | 349 | ||
| 52 - A 65-Year-Old Postmenopausal Woman With Abdominal Distension\r | 350 | ||
| What are the next steps in the evaluation of this patient? | 350 | ||
| How is epithelial ovarian cancer staged? | 351 | ||
| What are the goals of surgery for ovarian cancer? | 351 | ||
| What does the patient do next? | 353 | ||
| Case Summary | 354 | ||
| References | 354 | ||
| 53 - A 52-Year-Old Perimenopausal Woman With Irregular Bleeding\r | 355 | ||
| What are your next steps? | 355 | ||
| What is the likely diagnosis? | 355 | ||
| What is the incidence of cervical cancer? | 355 | ||
| What are some risk factors for the development of cervical cancer? | 355 | ||
| What are the main histologic subtypes of cervical cancer? | 356 | ||
| What is the pathogenesis for cervical cancer? | 356 | ||
| How is cervical cancer staged? | 356 | ||
| How is cervical cancer treated? | 357 | ||
| What is the recommended treatment of early-stage cervical cancer? | 357 | ||
| What is chemoradiation for cervical cancer? | 358 | ||
| What is a radical hysterectomy? | 358 | ||
| Case Summary | 359 | ||
| References | 360 | ||
| 54 - A 58-Year-Old Woman With Postmenopausal Bleeding\r | 361 | ||
| What can cause postmenopausal bleeding? | 361 | ||
| With what symptoms does a patient with endometrial cancer usually present? | 361 | ||
| What are risk factors for endometrial cancer? | 361 | ||
| How do you classify endometrial cancer? | 362 | ||
| What is the initial evaluation of endometrial cancer? | 362 | ||
| What tests should be ordered for evaluation of endometrial cancer and presurgical planning? | 363 | ||
| What is the treatment for endometrial cancer? | 363 | ||
| Does the patient need additional treatment? | 364 | ||
| How common is recurrence, and what could be done if the cancer returns? | 364 | ||
| What does the patient do next? | 364 | ||
| Case Summary | 365 | ||
| References | 365 | ||
| 55 - A 35-Year-Old Woman With a Family History of Ovarian Cancer\r | 366 | ||
| Which inherited genetic disorders carry an increased risk of ovarian cancer? | 366 | ||
| Who should be offered hereditary cancer risk assessment for hereditary breast and ovarian cancers?\r | 366 | ||
| What genetic testing should be offered to women with or at increased risk of ovarian/fallopiantube/primary peritoneal cancer?\r | 366 | ||
| What is the BRCA gene, and how common are mutations? | 367 | ||
| What is the lifetime risk of ovarian and breast cancer in a patient with BRCA mutation? | 368 | ||
| How should a risk-reducing BSO be performed? | 369 | ||
| Case Summary | 370 | ||
| References | 370 | ||
| 56 - A 29-Year-Old Woman With Vaginal Bleeding\r | 371 | ||
| What is the differential diagnosis of vaginal bleeding? | 371 | ||
| What is the most likely diagnosis? | 371 | ||
| Who is at risk for developing GTN? | 373 | ||
| What are the next steps for diagnosis in our patient? | 373 | ||
| Where is GTN most likely to metastasize? | 373 | ||
| What laboratory or imaging studies should be ordered? | 373 | ||
| How is GTN staged? | 373 | ||
| How is GTN treated? | 373 | ||
| How should this patient be monitored? | 374 | ||
| Case Summary | 375 | ||
| References | 375 | ||
| 57 - A 63-Year-Old With Known Ovarian Cancer and New-Onset Abdominal Symptoms\r | 376 | ||
| What are the next steps in this patient’s care? | 376 | ||
| What are options for treatment for recurrent epithelial ovarian cancer? | 376 | ||
| What chemotherapy is given at the time of recurrent ovarian cancer? | 378 | ||
| What options does the patient have now? | 378 | ||
| What is palliative care? | 378 | ||
| What is the patient’s diagnosis at this time? | 379 | ||
| What is the management of SBO in this patient? | 379 | ||
| What is hospice? | 380 | ||
| Case Summary | 381 | ||
| References | 381 | ||
| 58 - A 57-Year-Old Woman With Pain on Sexual Intercourse\r | 382 | ||
| Why is it important to ask about and address sexual concerns among women? | 382 | ||
| When a woman has pain with intercourse, what do you need to know about her history? | 382 | ||
| What clues in the history might point toward vaginal atrophy? | 383 | ||
| What clues in the history might point toward a musculoskeletal origin of the pain? | 383 | ||
| In addition to evaluating the vaginal mucosa for atrophy and the pelvic muscles for pain, what other information should be gathered from this patient on pelvic exam?\r | 383 | ||
| What is the foreign body in this woman’s vagina, and how does that relate to her pain? | 384 | ||
| What treatment options exist for this woman’s vaginal mesh erosion? | 384 | ||
| What does the patient need to know prior to having the mesh removed? | 385 | ||
| What treatments can you offer the patient at this point? | 385 | ||
| Case Summary | 386 | ||
| References | 386 | ||
| 59 - A 62-Year-Old Woman With Urinary Urgency and Incontinence\r | 387 | ||
| What are some causes of urinary frequency and urgency? | 387 | ||
| What initial workup should be performed at her first visit? | 387 | ||
| What is the patient’s likely diagnosis? | 388 | ||
| What are some first-line therapies to treat OAB? | 388 | ||
| What medical treatment can you offer the patient, and what is the mechanism of action? | 389 | ||
| What third-line treatments exist for the treatment of OAB? | 389 | ||
| Case Summary | 392 | ||
| References | 392 | ||
| 60 - A 51-Year-Old With Frequent Urinary Tract Infections and Vaginal Dryness and Burning\r | 393 | ||
| What type of history is important to discuss with this patient and why? | 393 | ||
| What are physical signs of GSM? What physical exam is indicated to evaluate this patient? | 393 | ||
| How do you establish a diagnosis of recurrent UTI in this patient? | 394 | ||
| What are the common organisms isolated in recurrent UTIs? | 395 | ||
| What are the risk factors for recurrent UTIs in postmenopausal women? | 395 | ||
| How would you manage recurrent UTIs in the postmenopausal woman? | 395 | ||
| What measures can be taken to prevent recurrent UTIs? | 396 | ||
| What treatments can you offer the patient for her GSM? | 396 | ||
| Case Summary | 398 | ||
| References | 398 | ||
| 61 - A 32-Year-Old Woman With Urinary Leakage on Exercise\r | 399 | ||
| What are risks factors for stress incontinence? | 399 | ||
| Why does SUI occur? | 399 | ||
| Is there any additional workup needed to make the diagnosis of SUI? | 399 | ||
| What treatment options are available to her? | 400 | ||
| Do you need to perform urodynamic testing prior to antiincontinence surgery? | 401 | ||
| What surgical options are available to treat stress incontinence? | 402 | ||
| What are the potential risks to mid-urethral slings?\r | 402 | ||
| What is the success rate of the operations to treat stress incontinence? | 402 | ||
| Case Summary | 403 | ||
| References | 403 | ||
| 62 - A 43-Year-Old Woman With Pelvic Pain, Symptoms of Bladder Infections Despite Negative Urine Cultures\r | 404 | ||
| Why is it important to differentiate urinary frequency with pain from urinary urgency? | 404 | ||
| What is the relationship between IC/BPS and other pain disorders? | 405 | ||
| What are important elements of the physical exam if IC/BPS is suspected? | 405 | ||
| Are there any diagnostic tests to solidify the IC/BPS diagnosis? | 405 | ||
| What is important for the patient to know about IC/BPS? | 406 | ||
| Which treatments are most effective for IC/BPS? | 406 | ||
| What other therapies can be offered to this patient? | 407 | ||
| Case Summary | 408 | ||
| References | 408 | ||
| 63 - A 65-Year-Old With Vaginal Bulge and Pelvic Pressure\r | 409 | ||
| What questions should you ask when obtaining the patient’s history? | 409 | ||
| What are some risks factors for POP? | 409 | ||
| What are key physical findings that you should look for? | 409 | ||
| What additional workup should be performed for this patient? | 412 | ||
| What are the risks of not intervening? | 412 | ||
| What nonsurgical options can you offer to the patient? | 412 | ||
| What surgical modalities are available for her? | 412 | ||
| How do you counsel her about the long-term durability of a POP surgery? | 413 | ||
| Case Summary | 414 | ||
| References | 414 | ||
| 64 - A 63-Year-Old Woman With Fecal Incontinence\r | 415 | ||
| Why is it important to ask about fecal incontinence in women? | 415 | ||
| When a woman presents with FI, what should you ask about her history? | 415 | ||
| What is the role of an obstetric history when evaluating a woman with FI? | 416 | ||
| In addition to obstetrical injuries, what are other risk factors associated with FI? | 416 | ||
| What is the physiology of normal defecation? | 416 | ||
| What anatomic components are responsible for continence? | 416 | ||
| What physical exam findings are important for the evaluation of FI? | 417 | ||
| What studies are necessary for the workup of FI? | 417 | ||
| What are other initial treatment options that should be offered to the patient? | 418 | ||
| What other nonsurgical interventions are available to patients for FI? | 418 | ||
| When should surgical options for FI be offered to patients, and what common surgical options are available?\r | 418 | ||
| Case Summary | 419 | ||
| References | 419 | ||
| INDEX | 420 | ||
| A | 420 | ||
| B | 422 | ||
| C | 422 | ||
| D | 424 | ||
| E | 425 | ||
| F | 426 | ||
| G | 427 | ||
| H | 428 | ||
| I | 429 | ||
| K | 431 | ||
| L | 431 | ||
| M | 432 | ||
| N | 433 | ||
| O | 433 | ||
| P | 434 | ||
| Q | 439 | ||
| R | 439 | ||
| S | 440 | ||
| T | 441 | ||
| U | 442 | ||
| V | 443 | ||
| W | 444 | ||
| X | 444 | ||
| Z | 444 |