STEP 2 CS OBS &GYNE-amenorrhea
O&G history mnemonic
LMP RTV CS PAPS
Assosciated symptoms of amenorrhea
LMP RTV CS PAPS
LMP
, Lactation (breast milk discharge/tenderness)
Menarcheat what age?
Period ( how many days does your period last?)
Regularity(are ur period regular?/ have u noticed any irregularity?)
Tampons, (how mny tampons/pads u use per day?)
Vaginal discharge(if yes,onset,color,odor?),
itching , dryness,
Cramps with periods? / Contraceptive use?
Spotting(do u blled in btw ur period? / post
coital ?)
Pregnancy (how mny times? vaginal?complication?)
Abortion / miscarriage,
PAP smear (when?result ? history of abnormal result?)
STD hx
ROS -THEN FR CS SAW PUB ID
T rauma/ T ravel recently?
H eadache
E dema
N ausea/vomit
F ever/chills,night sweat , Fatigue
R ash, Racing of heart
C hest pain, Cough(sputum,odor,color,blood)
Stress, SOB, Skin/hair changes
S leep pattern
A ppetite
Weight (how much? time?intention?)
Pain in joints
Urinary problem
Bowel problem (abdominal pain, diarhea,constipate?)
Infection(recent)
DIZZY
## remember ask whether is this planned pregnancy,desired pregnancy,domestic abuse?
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
- HEENT exam-inspection/palpation of thyroid
- Pulmonary exam: Auscultation
- Cardiovascular exam: Auscultation
- Abdominal exam: Auscultation, palpation, percussion
- skin exam : inspected for pigmentation or pallor
DIFFERENTIAL DIAGNOSIS for O&G History Mnemonic
- All females in reproductive age
- Pregnancy
- Amenorrhea
- Dysmenorrhea (Endometriosis)
- Domestic violence
- Depression
- Infertility
- Sexually transmitted disease
- Females who are going through menopause
- Dyspareunia
Assosciated symptoms of amenorrhea
HAG V FWL HIDC
H- Hair and skin changes for hypothyroidism/ hirsuitism of PCOS /headaches
A- Anorexia nervosa/ anxiety and depression
G- galactorrhea
V- visual disturbance / virlization /
F- fatigue ,
W- weight changes, appetite and diet ,
L- libido ,
H- hot flashes ,
I- insomnia,
D- deep voice changes,
C- cold intolerance, constipation
H- Hair and skin changes for hypothyroidism/ hirsuitism of PCOS /headaches
A- Anorexia nervosa/ anxiety and depression
G- galactorrhea
V- visual disturbance / virlization /
F- fatigue ,
W- weight changes, appetite and diet ,
L- libido ,
H- hot flashes ,
I- insomnia,
D- deep voice changes,
C- cold intolerance, constipation
AMENORRHEA CAUSES
AMENORRHEA
****1ST IS ALWAYS PREGNANCY
A- AMENORHEA, ABSENT OVULATION (PCOS)
M - MENOPAUSEA
E- EATING DISORDER(anorexia),VIGOROUS EXERCISE
N- NURSING MOTHER
O- OCP USE
R- RAISED PROLACTIN/ADRENAL HORMONOES
H- HYPOTHRYROIDISM, HEMORRHAGE
A - ANXIETY,ASSHERNMAN SYNDROME
PREMATURE OVARIAN FAILURE
****1ST IS ALWAYS PREGNANCY
A- AMENORHEA, ABSENT OVULATION (PCOS)
M - MENOPAUSEA
E- EATING DISORDER(anorexia),VIGOROUS EXERCISE
N- NURSING MOTHER
O- OCP USE
R- RAISED PROLACTIN/ADRENAL HORMONOES
H- HYPOTHRYROIDISM, HEMORRHAGE
A - ANXIETY,ASSHERNMAN SYNDROME
PREMATURE OVARIAN FAILURE
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case 1 amenorrhea:
40y
F w/ amenorrhea, morning N/V, fatigue, polyuria. LMP 6wks ago. Breasts
full and tender. Uses rhythm method for contraception.
W/U:
DDX:
- Pregnancy
- anovulatory cycle,
- hyperprolactinemia,
- UTI,
- thyroid disease
pelvic exam, urine hCG, U/S-pelvis, CBC, electrolytes, U/A, urine
culture, prolactin, TSH, baseline pap smear, cervical cultures, rubella
antibody, HIV antibody, HepB surface antigen, VDRL/RPR
CASE 2 AMENORRHEA:
23y obese F w amenorrhea x6mo. +Facial hair and infertility x3yrs.
- PCOS
- thyroid disease,
- hyperprolactinemia,
- pregnancy,
- ovarian or
- adrenal malignancy,
- premature ovarian failure
pelvic exam, urine hCG, U/S-pelvis, LH/FSH, TSH, prolactin, testosterone, DHEAS
CASE 3 AMENORRHEA
35y F w amenorrhea, galactorrhea, visual field defects, H/A 6mo.
DDX:
- Prolactinoma
- pregnancy,
- thyroid disease,
- premature ovarian failure,
- pituitary tumor
pelvic exam, breast exam, urine hCG, prolactin, LH/FSH, TSH, MRI-brain
CASE 4 AMENORRHEA:
48y F w/ amenorrhea x6mo. +Hot flashes, night sweats, emotional lability, dyspareunia.
- Menopause
- pregnancy,
- pituitary tumor,
- thyroid disease
pelvic exam, urine hCG, LH/FSH, TSH, prolactin, testosterone, DHEAS, CBC, MRI-brain
CASE 5 AMENORRHEA:
35y
F w/ amenorrhea, cold intolerance, coarse hair, wt loss, fatigue. Hx
abruptio placentae -> hypovolemic shock + failure of lactation 2yrs
ago.
- Sheehan syndrome
- premature ovarian failure,
- pituitary tumor,
- thyroid disease,
- Asherman syndrome
pelvic exam, urine hCG, LH/FSH, TSH, prolactin, testosterone, DHEAS, CBC, MRI-brain
CASE 6 AMENORRHEA:
18y F w/ amenorrhea x4mo. 5'6" and 90lb. Hx vigorous exercise and cold intolerance.
DDX:
Anorexia nervosa
PREGNANCY
HYPERTHYROIDISM
W/U:
CBC, TSH, FT4, ACTH, FSH, LH
CASE 7 AMENORRHEA:
- Anxiety-induced amenorrhea
- PTSD
- DEPRESSIONHYPERTHYROIDISM
W/U:
CBC, TSH, FT4, ACTH, urine cortisol, progesterone challenge, FSH/LH/estradiol
------------------------------------------------------------------------------------------------
patient notes:
History
HPI:
28yo G0 presents with a positive3 pregnancy test. Her LMP was 6 weeks ago and was unusually scant. She reports bilateral breast engorgement, poor apetite,nausea with no vomiting,increased urinary frequency,and feeling bloated and fatigue. She is sexually active with her husband only ,with coital interrupts as the only methods of contraception. This is unplanned pregnancy,and she is unsure whhther she will continue.
O&G: G0,menarche at age 14,has regular periods 4-5/30. No history of STDs;last pap smear was taken 8months ago and was normal.
ROS: denies abnormal bleeding,abdominal pain,fever,sob,or change in bowel habits.
allergies:NKDA
medication: multivitamins
PMH:none
PSH: appendectomy at age 20
SH: no smoking ,1-2 beers/week, no illicit drugs. Married graduate student ;denies domestic violence
FH: father is a diabetic. mother has thyroid problems and obesity.
PHYSICAL EXAMINATION
pt appears comfortable.
VS: WNL
HEENT: NC/AT, PERRLA, no icterus,no pallor,mouth and oropharynx normal.
HEENT: NC/AT, PERRLA, no icterus,no pallor,mouth and oropharynx normal.
neck: no thyroid enlargement
chest: clear sound bilaterally
heart:RRR, nomral S1 S2 ,no murmurs,rubs and gallops.
abdomen: soft,nontender,nondistended,positive BS, no evidence of guarding or hepatosplenomegaly
DDX:
Diagnosis 1 Normal pregnancy
hx findings:
amenorrhea for 6 weeeks
positive pregnanyc test
bilateral breast engorgement
nausea and weight gain
Diagnosis 2 ectopic pregnancy
hx findings:
amenorrhea for 6 weeks
positive pregnancy test
diagnosis 3: molar pregnancy
hx findings
positive pregnancy test
nausea
diagnostic workup:
Urine hCG
U/S pelvis
breast/pelvic examination
Blood type/Rh,antibody screen
CBC
TSH
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dysparunia - DATIVE
D- Domestic abuse
A- atrophic vaginitis, don't forget to ask about signs and symptoms of menopause
T- tumor of pelvic
I- pelvic infection,(Vulvovaginitis,cervicitis,PID)
V- vaginismus ,
E- endometriosis don't forget to ask about cyclic pelvic pain
A- atrophic vaginitis, don't forget to ask about signs and symptoms of menopause
T- tumor of pelvic
I- pelvic infection,(Vulvovaginitis,cervicitis,PID)
V- vaginismus ,
E- endometriosis don't forget to ask about cyclic pelvic pain
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