Contents

ObSl.mcs Bonu, C1lS~1

Section I. Obstetrics/Gynemlogy

Chapter1. Obsit'tricsCases

Chapt~r 1. Gynecology rases Gynecology Boous Cases

Section II. Pediatrics

Supplement

Section Ill. Surgery

SurgeryGlses. Surgery Sonus cees

Section IV. Psychiillry& Ethics

ClYplerl. Psycili.lry(as..s.

I';ychialryBonusCase5

C","pler2.

iMCIlcaI V

Contents

Section I. Internal Medicine

Chlpterl GMtroenterologyC=.

G.lS!rOenlerologyllonU'iUses ........•......•......•. 37

Chilplell. Rheumatologycases.

CMplerl. EndooinologyCase<; 49

EndocrinoiOfiBonU'iCases

Cllaple.4. EmergencyMedicineCa>6 .

EmergenCVMelIicin~80nu! Cases ..

CbiplffS. CardiologyCase:l.

Cudio\ogyBonusCas.es.

ClIIIpleI6.HematoIogy~ ..

HematologyBonusCase'i.

Clo;Ipler7.0ocologyOlse:s

On((llogyBonusCases

Chapter 8. InfedtousDis.",esCam ..

InfectloosDi~.,es80nu!(a<;e5 ..

a._plug, NephrologyCases

ChaplK10. PIJlmooologyCMes •.

I'IJI/l'IOOOkIgvBonusUses ..

ii_llcal Y

NeuroIogyCases .• Neurology 800us Cases

USMLEStepl:SedlalHeid

Section ll. NeuTology

Obstetrics 1

CASE 1

Chiet complajnt "I'n\,,,,,,,,,onth.!lat<formyp,,,iod,"

Histosy and physical examination

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

• 5<wn<iuyamenonbn.probabiyau.oedbypregnancy

OiffetentialdiagtlOSis

Inilialdiagnosticplan Results

I.Urin,p.hCG

l,Urin<i<.rt<>n<<!,,,,,df"gr.';ty l.Weigh.

Trace kfton";'pe<:ific llravi'y 1.011

12, Ib (und>anged from postl'ew month.)

Probobl<in,uut<rin<p<ogn.oncy.MM"rin<lI--hCG<h.o", ... ""j';'i1y''''''''comporab!.,o

::'.~ ~~;.:: ~::;~';f::;~;":':. ~!~':~il~~~~~'~::::!'~~~:::'=: i

ti"",o ,ul,out Qthe'otiologid befo .... ttr;butingi'to norm.1 p'cgn."cy, Mol .. pregnand .. ,ndhyp<rthyroidi,m,i>ooanp""'ntasn""",.and'ofl\iting

1, '~:~!d.llimul'liDghormone,

furtherdiagoowcplan Rewlts

Tr('almer1tplan

t_Pr<pa"'l'roun .. ling(.midolC(lhol.l~hyp<nh<TIllia)

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'

4. Relurnvi,;tin4 .... ks(upl02Sw«Iu,th,ntvttylweoksuploJ6,..,.ks,thonw«k1yunhl <1<1;""'1'1

Discussion

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.

Oifferenti<lldi<lgnosis

Hydaticliformrnok

• E<topicp.-.gn.ncy

lnfialdiagnosfk plan Results

I. Q".ntit"iv<5Orum~-"CG 2. CornpJet<blood<oum

l. So""W'm

HcrnoglobinJ2.0g/dl.Mrnatoai,37% lntr.u~;n<.ingl"""p<qniD<J'.<n>wn"""p l.,-,gtho!8w«k<.r.,olcaRliacrnoriO"Jm$<n, Ap"'im-e;atypi<ol.ntibodroc=nnegativ<

4.1\'p<.nd.,,,,,,,,,

l'h",lt<n,d,boltion;,J;.sno,," with fi"ttrirnestcrbl<cd;ngin thop"" nceof,"'nograph ie,llynorm,lpregnancy,nd'''IO"oooi«",kald;Jotion

Treatment plan

t. R" ... u"'thep.1ti<n'of'h<f.""rab"progn""isinJightofth.",,~,;"i<taIcardiaca<ti.;,y.

2. Rou'in<foU"",_up.ln>tnlcthtftoGdlif'h<has,."Orsrningp.1in,bt..din~f ..... r.chilI"oT'he p .... l!<0ftissu"'-

Discussion

Th",,""edo:borricm occurs in appl'<lXinu .. 1y 20 10 25%ofall p'cgnm<ie>with only aboo'on, b.tlfof!hes<pr<gnan<ieomdingin<omplttoabort;on.Apprmimately8O'lE>ofaU.bonionsocau ;n.h.fir>l~ .... Th,rUkofJ'f<5"lncy'<rmin.1tin~in'po<>lan", .. .oorti""increausindc. pmdc.ntlywitbinc=in!"'";tY.ll\ltemal'll'.andpatemilage.Th<m.;o,,,,,,,,",ofllbortion;' gt'Iletic.withan.n,upluidillCi<kneeof5O'!l>.Alil"..,maltri>OJJlj';",b<mo>tcommon,l'P"

Th.foUowingareallfir>l"im"'<rdi.g"""'~

• Mjs,«!allortioni,di.gno,..;linth •• b..,nceofbl<e<!inso,,,,mpingwhon.,,,nogram show<<ith".n.mp'ygest .. iool.l"cn,thoab>cna:of,viableembryOorrotu, M.n.gem.nt<onb •• i!h",on,",",hvtob>ervationorsche<luJe<I,uct;onciil."t;on .ndourett.g,.

·!"m,obl •• t..",io";"di,gnose<Iwithv.gin.lbluding.nddilatedint<",aleervi""lo. bu,.h=:t«ofP'''''g<ofp,oductofcolK<ptiOlL)..lanajJement;''.morgency,ue.inn diJatation.ndmr<ttas,·

• In(ompl<,..bo,ho"isdi'gnOOO<iwilhvaginalbl...:lingonddil,tedintem.1ieervinIOl withsom.pto<loctof<oneeptionp.....tvogimilly.SOnograrnmow., ... in«i in""oterin<d<bris.Manag.,.,.n';,<m<fi<ncy.uc!iondiJatationandru.....,.g< •

• Ccmpktbl.b.>rrio" isd .. gr.o>ed "';'h .... nil bkcding:rnd pa»ag< of tb< produ<l of ::,.~nr:;;_Sono8 ... m mo... normolcnclomrtrial >tripe.Managemen' ;.<o .... ""'r;..,

It;,ilioimpo' .. n'to'Omini.'<tIlhoGAMforp.tientswbo.r.RhnegatMwhop .... ntwi.h rnyoftbes<diagnOO<S.

Finaldiagoosis

Fi ..... rtmes<"'blccding

i "".... ..

I ~irn!dAt>ortioo

'5ymptoms,,,,ab>en,,,ofbleedin80fa,mpin&

1_ .. "' .... itlter."emptygeslatiooalsa(_"f't>sence1lf.vi'bl~em"ryo.orfeilll

I ·M,nagemenI"",,beeitherCOrwrv_WservatJooOf"dle.MedsuctJolld~..,d

~-

InMablo~

·~.revag; .. lbI~ng"'d(ri!fllpin&"'hotJpaISolgeolproduttol(l)1(epIiM • Sig""redliote<l,mernal<:ervical.

IIydatidiI"""MoIe ·5)mploolSore....typresrl¥lCl'~witfI~~¥tdIOf_on<e!oI hlPf1l1rtT<idism

·Signs.revasinaibleeding .. ilhp<.lSlible"8inal"gr.pelike·~1es

• L'OOTatorylindin ..... e.ilnormailyhi&flquantil'live<erum ~-hCG(us~lfy>IO!l,OO!JmlU)

• 5)mplOm$wben"MlPftln!d~,meroonI'I&l."agWIoIbIeed"'aodu ...... allower"!>doininaI-

.......

• SignI"",wg;flillblMfil&do5eoji'temllt..w:.l""ofMlenlalged<lel"'-

• ~:"~U~''''''''''''otirn'aoIcrinegestalionlJlSiKlilenqUif1WIivest'<UmJl-hCGis

• Ma .. gem"'l~eith",melhOlre..'I.o'I'p,rOS<o~.

USMLE5tep3:0bs'lelrif;5/GynOOllogy

Dilferentialdiagnosis

• !'.ctopk pt<~n.nc,.

• Ovarian cyst

• Appendicitis

Results

Hemoglobin 13.0

Ectopicpregnmcyisthepre,umptivediog"'lSi,wilnnoinl",,,torin'PT<gnancywithtransvaginal ultrasoundinth'p",sen"ofq,",nli,",i' .. s<'um~·hCG~I,500mJU.

6 K*llcal

Discu5.'Iioo

Th, otherdllJerential di.g.no",. (p,d";" inn.n"".torydi ... =>.pp<"di"ti~endom"'rj",i •• o."i.n'1"t),aithoughthey"<all."""",alwithp<lvicp.m.me"lud«lbj,.,,,,<iti,,,,(}_hCG

M .... g ....... tOptio On« th.diognooioof«1opk preJlnan<y~bccn ",ado,. manag<men'

pl.nioimp""'iV<.W" «>m.<etopicpregn.ncieo'pon .. neously,."'I .. ,lIl,yhave,ig.nifi

co"'potentiaifori""-'<iins,·,><ui.o,,,,u""re.l,,dingtolifNhr<at<ninghemorrh'ge

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.

Finald~gnosis ectopi<p •• gn.,,,,y

~1caI 7

USMLESlepl:~ricsfGyneo:ology

I ;;;;~;;~'kwyDj:=--~;~-Rmew - -----=1

I . >ymptoms.rebiIJ'a"'kIw"-,bdomi",lpel~,p,in I

• Si80<"'m"coP"rulenl,ervicaldi""'r& •• nd" .. vi~'motiontende,""".

• laboralory!indingsare~ev>teJWIlClo""I,,,d"rylimxvt.,edimelll'lionratf i

• Milnag,melll ""n be e:1h'" olltpatieotor ;"palientJn~bi01ir:s, depelldio8 on the Sjle£ilir;(lISe I

·MJnogemeoti<5ursical'f1lo"deaomy.

8 iiHKIlcal

CAS"

Chiefcomplaim

SuddC1lon.lClof.Wominaipain{in=asinginin,.n'ity),r.""r,loth''iY,weo!uJ<>s,..,dv,ginal <p<>ning

Hi~rvandphysicalexamination

~ 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~

Initial diagnostic plan I. Qu,n'ilativ<p.hCG

l. Compl<t.bl<><><lrounlwi'hdifferenti.!

Results

WBC. 21,OOOlmm', hemoglobin 13'> gldl"h<m.(ocri'}')%

R<loinedpro<iu<ueon ......... nidos[orinfection

furtherdiagooslicplan I.UI" .. ound(''''''''''ginal)

Asse!;Sment 1'<>".bort.l<ndomf'.'pmm,(fitis

Treatment plan

I.UI<r;n ..... < .. ';onwi(hdll ... tiQn.nJc"'<ttag<

2.lI!oad·'p«:Irumimro"."""" ... tibioti.:..wch ... mpicillin.g<n<>mycin • ."ddindamycin. lOa>Wrpolymitrnbiollio .. ( .. p<ciaily.n .. robeI)

3. FoUo..do .. lyto p,..-rn'"'pti<>hocl<.

USMLESlepl:Obstetri«/G)'1IHOlogy

Discussion

Final diagnosis 5<pticaoortion

iEOOOmelrio<i<

• S)IllplOm,m,yind"deinfertifily.<¥P",,,mi'.M<ldY'fh.,i,

A~~di,iti,

• Symplom5,reri~llowerq"ad"nt~'i"

O\Ia""o(1"1 '>)Illpiornsareuoilaterallower-abdomio,l-pelvi'l"in

10 iMilical

CAS"

Chiefcom~ainl

Fi"'pro .... (,i,;1

History and physical e~aminillion

Diflerenlialdiagnosi!;

l..,imm~niz,"ion ... ith"'hDodies.gairutcitb .. th<['l.n'ig<""'!iOftI<o'horRI!C.ntig<n

InHial diagoostic plan I,Typinsofthe.nlibody

Results

Discussion

Th<p_nuof.typical.nhbodiesconfirm'th'diar.nosi,ofi .... immunizatiQn_lheriskoff<1al an""';."'pr<Jica'..JQ"~""prerequi<ites:(J}th'moth"io.nligcn""sali .. ,(l)'hef.the,isaon_ grnposilM.(j).typicalantibadie<arep' .... ntinthemoth .... '.<ircul.olion.f4} the antibodies are ....,.,ilt<dwilhh<molylicdiseaseofth<newborn, ... d(5).h •• nlibodY'i'<rj'''''''':8./ustbecause th<.,.lim1isllh_ti"",onecannotassumeth<.typkalan'ibodyisdi"",'tdagainsttheDanri. grn.l'io importan, '0 sprciIkaIIy 'tl'" Ihe ... nllody and dfttormin< wh.d,., i,k...oo..led with h<rnoIyIi<dis<aseofth< ..... """"-Someantibodioo,_h .. Ltwis,<W<t<>!""UI<RIlC~ _,rl .... <l how high thciJ-ti'a migl" t>e. 1I«a"",.n,i·t.:d! antibodi .. ",,_.,.,j "'id, lH:rnolyticdisc- ... ofth< MWborn, i'isiml'OTtiln' ,oJ.:t<rmin<,h< ,il<t.

HisRIK:.ar<Kellpo,iliv<

Treatment plan

I. FQllowmQ".hlyan!i.K<ll tit<r~

~lcIIlll

USMLESlep3:ObstetricsjG'fIIIKD1ogy

12 iii8iacal

CASE 6

Chiet ccmplaint

History and physical e1.ilmination

• Multipleg,,,,tion

Co<>g,nitainephro,i,

• Placentalble€ding

Initial diagnostic pian Results

Treatment plan

~cal 13

U5MlESt~p 3: ObstelricslCynecology

Discussion

Term;nat;onofapregMncy,houldnotberecommendedonth,bas;,ofmatetnal""un,.lph. fetalprotdntestinsalone.lti,a,m,n;ngt .. t'odefi"ewho;,ar,i,k,"d;'n" ... "rdi.~n"Sli'.

Final diagnosis

J)"in3<"'"within<"'."'d,"'t<m.I'"um.lph.-f<t.ll" .... ";n

14 meCilca1

eASE 7

Hstorv end physkalexamlnanon

In~ialdiognoslicplan 1. Triple markcrS"'·<n

D"""",,;n ",,,ern.1 .",um ,Iph •• fctoprotein ,nd E); in<r<ase in ~·hCG

2.Valprok.ddl,,",1

metlical IS

USMlEStep3:0bsletrits/GI"'t<lIlogy

Trisomyl!fctu,

Discussion

16 iiMKHcaI

CASE. Part I

History and physical examinatJon

Differential diagnosis

o False pmitivediab"icscre<n

iiiiMkaI 17

USMLEStep3:Obsteb .. 'o.,..I''!'''_="---- _

Part II: Three Weeks After a Trial of Diet Conlrol

History ami physical examination

• Gostotionaldi,betoswithfailoddictarythcrapy

Treatmentpliln

2.Starttwicow«k1ynon'''e>.ttst •• arnnioticfluidindex,orbiophysicalprofiles.

18 mec.1caI

P3r1 III: Six Weeks teter in the Maternity Unit

Results

M"rusomi,infan'Gfadiab«icmoth<Twithneon"albrachiaipiexu,injury

~cal 19

U5Mu:5tep3:Obstetrks/Gynecoiogy

TkMcRobertsmaneu ..... n'.iloflaingtlo.'''''I.rnoIlhighsand''' .. tingili<legs''''1101o:nlly 1"iocreasetlo • .u.oflh<m.I<f""lpelv;..$up .. pubic(>TC'5U"''''''y ...... I'inmobili1in&ili< jmpaCledfetal"'ouJd<r.pennjttin&dcliV<fYof",.an"'rior,hould<f.Otbefm.1 ....... ~.n .. il

Wid<epi<io,ornyandlorprot,o",rny The Jeliveryof'h<po" ... k>"houlol<, R01.,;ng 'he baby

• Proionged second ,tag< url.bo,

• O<ytocioioduc<;onQr,ugrnen"'ionoflabor

• U .. of .. si"«ivaginalddi""ry

• Pro!nCleddt«len';"nplw<

Avo;danceoflh ... sit ... 'i<m.c.ntldpd."' .... 1h.iocideno:.o"fbio1h"..u ..... Aft .. 'h.,.Jur... OCCUfred.ther< isUn:I<OCIm, ''''''Jr)<1I,.ha'canben>ed ,,,,,,,,,,,,,Ib,de(OC;L

Fillilldiagoosis

G .. tationaldiabet",and,hould"d),>lO<ia

lO~1caI

CASE 9

Chief complaint

"Mydoctorsa),>th.tmystornachi,n'tgrowingf.st'"OLlgh"

Historyandphysicale~mination

Differential diagnosis

• G<>1.tioo"ldating<rror

• !ntrautorincIj.fowth""tri<tion(lUGRI OiiguhyJromniu,

• Asymrn<tricintraut<rinegroy,1hremiction

• Ch",n"h)'1":rt"n,;on

Furl~diagnosti(plan Results

iiiMlicat 21

U5MUSlepJ:Oitstelrits/(;yneroIogy

DisMsion

Intrauterine growth restriction (IUGRj

\\n.reas 'h< uI''''(J\mol finding"how in.dequ.tt (c .. 1 g""",h, the (".1 mea,. remon, par.", etertlwi<mru,.ff«"di,th •• bd"",on_Thi,i,ronsi",n'witha>yrnm<fTi.-in'","'.,i"ogrowth r<S!riC';on.Th<f,(u,hA$normalgrowthpo,enri,ubu,;'prevent<'<lfrom.<1u.li,.ing;'by lad' ofnutrioonal ,uho,ra,ts from insufficien' pl.i«D",1 run<1i<>n. Themo<tro,,,monc.u>< i. ",.,crnoIhyp<r1<n.Km ... ;'prob.bltinthioca><.

Oligohydramnios

Oiigohyd"mnio.' i, di.sno>«i whon th. 'Um of the deepe" ,~rtical pock<" of .mnioti< Auid '<CIlbyuhr""oodin th. fourqu.d"n" (righ'UI'I"'"right I""". left lowo".nd ld '"PPOf)i. less,h.n ,rrn, Thi' is k""wn ."h.four-.guadr.mt.mni(>tic ~Wd ;"dex_An,n'fii01i, Hoid indcxof5,oScmi.oonkrHn«norm.lr;rngoi,6tol;crn)_Themoin""un:eof,mnioti,nuid ;.f<1alurination.liyp<r'rosioncanClu .. pl""""t>.li""'ffi.,;.,m:y,wru<ha.nd« ..... "'n.1 bJoodfto,,-andk..d 'ooligt>hydromniOl. D«=><d.mniotje O~id= , .. ult &"'" r.,al,nom> lies in",lving the kidrr<r. u .. , .... bladder, 0' urnJ..-. .. "",II ",,,,,,.,,.,01 m«iialion.( •. g.. indornerhacin.nd.cetykholin<"'era><inhibito,,)

Inlrauterin~ GrOWln R.striction oSyrnplOmo;m,ybe,b>rntor"",bIe oSign!~flJl1d.lfhejgl1tfesslhan~mrdate5-

o SmogramlOO""JaaIgray.th;;bOOwlmthpt'l'wtile_

CASE 10

Chief complaint "r",bl.,ding;

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.

Oifferentialdiagnosis

• Ul<rin<,uptul'<

• Bloody,how

• Low.rg.nitaltractl<>ion

Initial diagnostic plan

J. Compt<l<bloodo:><mt

H""'0iIIobin9g1dL,""""'oaitl7%.p"",let, 210,OOOImm'

4_Typeand>ere<n

PI",.nt.previ.i.th.mo"lik'lydi'~"u'i,withp.inl."thirdtrim<"<rhl«<ling

14~

Discussion

Further diagnostic plan Results

Treatment pian

Admit to maternity unit

~ieal 25

USMLESlepl:Obstetrics/Gynecology

Final diagnosis

16~1

CASE 11

Part I

History and ph)l5ical examination

9. Urinrtoxicoiogy

Ncg.tivc

~1ca127

USMLEStepl:Ob<'etrk'/GynKDlagy

Assessment

Discussion

28 iiMKIlcai

Part II: One Week later on the Maternity Unit

As~;sme~1

Th,wn, .. ningdinicalfindingshav<unequi'"OCllllymo,'od,hop"i.nlfrommildpreedarn",i. '0 >tW,," pr .. d"",,,,i._Th.,,i,eri.fo, ""vere p",,,,,I.mpsi. ,hat ,nc m,nibu;nd uokblood P""'"'" ~16OJIIO mm fig, 14-ho"' urine pm'';" ~ S. d.",lopm<n1 ofh .. dach<> '1'igaSlri<: p";r>,.1<>",«iliverrn<j'ID<>,a"dd;»<mmal«!inlravo>Culir'''''·S"lirtion.anfyoneoftb<s<i. "'*""'YlOm .... 'hediagOO5i>

Further ueetmera plan

Further discussion

Part III: Two Hours Later on the Maternity Unit

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

I'rnh,blc m.gne.ium toxicity

Further treatmenl p1.an

I. Admini".r,"ppl<m<ntaloxygen8tolOlit=bym .. k.

!.PfIC<OX}'B<n .. tur:ationmonitor_ J.S""in"· .. ..,.",.c.dciwngl",o,",,e_

"'Mical 19

USMLESlepl:ObstetricsjCiyneco,,'.,"'"---- _

Further discussion

• M'n,~ement ~ Slopping oei(lI!es with M~SO~ amihypertensil'e agenls. an~ prompt del:v.f)'

30 ... ecIJcal

I ChnmicHy~rlen~on

CtieReYiew(contilrwd)

·')Tllptom,m.yl>e,bsentorv"iable.

• Sign,m>USla'""dhwffimsiGn\.>14C\f90mmHglbelorepreg",nCjorb<!ore20weeks' ",,"00

C~r""k~nWtlh~rirnposedPr=l<rmpoia

• Sjmpt(llllsrmyirxludeIl101eofse, ... preed'm~a

• Siins"'IMs,ol(hmnichyperre",ionpllJ5li~"llbloodpt"""T~and/orlr.os.ol"",,re preect.mP5ia.

• Labora:oryfindings '" W{Ifoerlln8 ~rO!>inuriJ, hernoconceollOlion, IhromblX)1opeoi •• aod I"", ehl\'meeIeYation ·M,",g~"MgSO.se~"TeP"OpIljla:<i:!,.nIi""'"""~15,.nd".nmptdeiM.>ry.

HELLPSyndrom.

·~msrrnybeabsem", .. """'_

• SiEnsrmybe,bsen("r,ori,bIe

• l,bora1oryfindiogs.rehemol\'Sis,elMledl'",re"'Y""~","lowpl.JlelelS

iiMi&caI 31

USMLESlepJ:ObstelrlcsjGyoom!ogy

CASE 12

(hiel(ompiai~t

Hsterv end phvsicel examination

11 ",~Ical

Disrussion

l!;'iml"'rLanCto,<rogtIiulhotmo>,"mllCrm"·'r><ing>"'IIOI<>US<dbyfet .. hypoxia.Aa if'h.',aci"gh .. bio~pIausibiljcy.Th<follcwing'C<p.5houldbtto.ken"'h.., ... ."tlhee .. er n,lfe,olononitor'f>,ingi>notrc"",Ur1ng.

Confirm .bootm,1 finding: ,achyc:rrdi .. b ... dycatdill. d.",.,..J \"Otiability.'ever< vari,blo .Jec.I<r"ion.,Qr.nyl"odo«l .... tion~

Identify nonhyl"'.kca .... ,presentthatmnldozpLoin ,h •• bnorm" finding5' m.uemalfevcr. m<dbtionetroa.prettutIU,icy,orfetil1tfhythrni ..

Ini,;"t.th<inl"'"t.ti ... ""usci .. tionm",,,,,",(d<><Iibod.~""""lnitial~, PI.n).ornhoncepl.«ntalperfuOOnaodfetaloxrgrnation

Ob.<t .. fo,notm,liwionofth<<Xt<rn,lf lrnonite<ttacing

P .. p."fntdeliV<'Tpromptlyiflll=in ,Uion.<Ion<>tnorrn.liuth ..... rn .. f.talmonitor

tracing.

iMCIcal 33

CASE 13

Chieicomplainl

"I'm at 42 week,'s .. ,aliofi ,ndTonlyh,v<occ",ion.T contractions"

Part I

Historyandphysicalexaminabon

Dtflereotial diagnosi~

• Pmttcrmpregn'ncy

• !lllIaUIatedating

Inilialdiagnosticplan

l. M<n",ualhist0'Y",.iew<d

Assessment l'<J,td""'pr<gn,ncy

34 me&lcal

Discussion

Mos' obsl"rici.n, ind"", lobo", 4~ ..... ks. " .... n 'h, ri>l of imr.lu"rin. ,.,.1 do:mis< become< .ipifi,,,,,,.ln,hi,,,,, ... ,h.findingof.fou,-qu>dr.m,mlIlio,i,,6uidi!ldnou,,i<!eth<nomW ,angoof5,o2:;,miono,,,,,,,uring.nclinJicI, .. ddivcr;-

Part II: The Nexl Day in the Malernity Unil

Diff~rentialdiagnosis Frtalhypo·i.""><dbyplao",,,alin,"m,","<)No,,",' pnY'i~I"gi' fctaIS,moi"""in,lmo,ili'r

U5MLE51l!p3: OlKielrics,lGYlN!(GIoXV

In~ial diagno5tic plan Reo;ults

I. P!.«intemalfnalscalp<l<ctrod< eo"firm''''''<,."alf<talh~.nr.u.moni'o,findings

1. Amnioinfusionwith .. I;"" D=1 .... 'io..,h"·.di"'PI',,,,<d

Assessment

jreaiment plan

L(on,inue.",nioinfu,ionun,ilcloli""lf·

L_Suc,;onf<talno><andph"yn .. rt<,d.liveryof,hehead

3_ p.,.fQOmlarrnso><opic'r.r'h~.I •• p; ... ionafte,deliverrofth<f<"lbod;;

Discussion l1><mech."i<mfotp>ssag<ofm«on;u".;n,,,,,,,;,<;lhcr.adnsi,.m<diot<dl<>osof.nal <prul>C""onoo,m;"u,;'y.m<1!i"...!int.,,;n.lpc,ista!,i>.Thefnalmnnitorpottomi,""t,"Sgt>,;",ofac;dc>s;'.sn,hemo,t l;kdYOJpl.n.tinni, f,"I~"'ro;nt<s';n.l'roct m"udty.

Toprev""tn""".taI .. p;,.,ionofm<eoniumin,o,h<u""heobronchia!'t«.fl<rdel;"'ry.;,;, prud<n'top<rforrn.nc'ioni"~of'h.n'''''ph'''J'l1.-1onth'p«;neum.ndin1ub.o,<.nd'UClion ,h<D<01l.1te.To<llecu"in,ub"ioni"a'im<lyman"<r,clamp!<ut,h<<o,dp'ornptly.

Final Diagnosis

Pm,d>1es p'egnancy.nJ ",cooniom

16 .....

CASE 14

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

Differenlialdiagnosis , Ulerineatoll)'

, Rct.ineJplac,n"

• fJi.«millatedint"",,,,,ul"C<l"gul.'ion

Inilial management and diagnosic plan Results

2.1nr.-i$(J'onicOuioi>widoopcn l.Typ .. ndcrrn.smatchfortwo"nit<of

p.odo<!reJbloodcoll.

4. Complctebloodcount

S, Prrlp,,,,ul<ru,.bdomin,lly 6.PI .. ,.F"leyc",hettrinbl"lo«

u""u,f •• I,oofl.nddoughy

Post" ... "mlt<morrhagec.u><dbYUl.ti".atony

Sub5equem rnanagemenl and diagnostic plan r. Admini""'oigorousbim.lnualu''';rl<rn-=i<

2. Adminislerm1r.l","o"'OXl'IOCin,in'ramu><ularn,ethe'llolin.,ori"tr.mu!ICulor[:;mrthy!

F,~rrostaglandin

3, En,u",patirnLh.,o,.oe<omiLl,Jfor~",;(;oIt.w.tion,

1, ~n"'r<m't<rn.landfetalpl'L""t'I,,,rf.ce.<havebeen'<omin<JrQr<ompleten<"

USMLlSII!,l;ObstetrialG~ology

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

• Corlicallindingsarea so~ uterus palpable ,boweth. umIJiliclIS ·MJn"gI'memi,LJterine""""'ge,nduterotonicag'"ts(e,g,,oxytocin,melilj!ergonov;"e,or '''OOP''lSI)

• C1in~~finding<dlem""ingpll{el1ldl'or,oIedoo'inIOep'esenceof.wnt"ct.dot.'"'· MarlilIlt'l'CIlt~m,"wJrem"""

I~,,"',~,·("·( 'Risl.lactorsin<lud'ITl\'omel,i,'wea'r>e"(moslmmmoo),ndp,,,,,iou>u\e"n"rY'IerS1orc

· a'"'Qllmdongsar.,beefy.""pca""gbl,,,,dlni"""inlhev,~"","dl,,'"retoPJlpat.IOe ulerus~~omino"I_

• 'brlil8emellt~LJt.ri""repl"emerrtiJyel""'1In8IhEvagi"lltomices."dlrru"gtheLJtenJ> i upw"d,!ollo"<'<l b)'im",'""o,,, ""I'loon

jOisserni..atedlntrOMSWlar(oagul.1tian(Rore)

·R6kfacttnirodudeabnJpliopb; .. :iI(IIIOII<OmIlllIIt"""'.PIftdam.,.u. .... nioIi<fuid ~ondproklngedfetJllIernist_

• CM.c.!llindins>irdud.gener<>iledb.'eedinginthe~esenceola(o .a.d"""""-

• Mondsenent"rernO\Gllolp~"'yl!:lsueskcwnthe"terus.lm~ns "reooitSIJWOIt'nd

.... arwblood~OOIJarejJla<em.rll

me&tc.1 39

USMLESlep);ObstetriCS/Gyneoology

CASE 15: ETHICS AND LAW IN OBSTETRICS AND GYNECOLOGY

Adolescents

The fetus

Th<frtu,i:;notcoJlSid<rroapmoninth<eye,ofthel.w.ndb,,-,noioll"irighKAn<"''''goner c<SaIe>Jlsectionforfetalj<opaN)'canbeperforo,.doniywithdw,nuther',eonsent,

Thenewbom

40 meiucal

BONUS CASE A

(hiefmmplaint

Part I

History and physical examination

Diff&entialdiagnosis

Results

Cer";xisiong,ciosro,fLfm"ndpostorior WBC9.UOOlmm';h<mogiobin9.5gldL;h€maoocrit26%, MCV7'o.lIn)

m&CIlcal 41

USMlIStep};Ob§tetriujGyne(ology

Discussion

Final diagnosis Pr"ermi,borandanem;,

Part II: Two Hours After Observation and Repeat Cervical Examination in the Maternity Unit

Repeat(ervicale'am;nolionlhow,l-to2-UIldilation,1 m,lorlg,sofi,midpolitio;l UterinewntroctiQnsar¥nQw~"''Y3to4minutes.

Treatment plan

Discussion

42 ~Ical

Final diagnosis

USMLEslepl:Obstetrics/Gynecology

Part III: Two Days Later on the Maternity Unit

• Prematur<rup,ul'eofmembrane<

Further diagnostic plan Results

4.0b>tetricsanograrn

44 ~'&Ical

Discussion

Final diagnosis Preterm,prema,ureruptUfrofm<mbran<>

Part IV: Two Days later on the Maternity Unit

Diflerentialdiagnosis

• V"j,bl.d<o<i«atiunsfTorn,orJ,o<npr .. ,jon

• P""ibl<proiop>cdumbili<oioorcl

Fort:l\e( diagno~ti( plan

I, Ch,nS'm"ernalpo,j,jon 2,D;giulc<rvic.l<X.1rninarion

Re~ults

No change in ,·ariabl,d«<lc",ion. Aloopofumbilkalcordi.polp"nlin,hevagin.

Assessmenl Prol.pst<!umbili,a1cord

Disrus5ion

Aprol,p"';umbilic.lco..disarru.ob "k.rl1<rg<TIC)'.Th<rnainm"'.g.mn>tobje<"'''isto

"'li th<pr""""'of'h<p=<,'Ilin~r lportontlt<<o..d_Thi$ohouldbtd<>n.byekvd'ing

rn.p n'in!pm""dbypla<inS,h.po'i.n'incitherth<koeo-<he"J'O-litjonorin",,'.,><

Tr<ndel."burgro>ition.Oonot,U''''p''<>roplac<thecordinw ,h. ""rU~

BONUS CASE B

Chief complaint

Part I

History and physical examination

Differential diagnosis

Stagolofl,bor,I"'ntph'"

Initial diagnostic plan

I Ob,,,vation,,mbuia<io.>

~ica147

S="',J""8"b<si"' ... ;'bc.,,"pl<1 ..... 'addiiation.nd ... dsw;lbd .. ;V<1'Yo('honto""' •. Du'"'i""marbeup'olhQu";n.pr;m;fW".andlbourin."'ul';~UI<O(.pid\l .. l.n ... 1b"';.mayproJongdur .. ;onupl0Ibou, .... I:mo'mol;tiesincludeprolong<d>«Qndl!agO

Tlrird""8"b.gin,wi,hddi¥'ryo(,h'n<'Ollal<.nd<nd'''i,hddivt"rYof,h<piJc<"'".I)",.,fon 11llIj'beUplo30minu ... ;n,lIwom<n .... bno'malili .. indud<prolong<tlthi,d""I!'".

Part II: Four Hours tater on the MatemityUnil

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

In~ialmanagemenlplan Results

Uterincconlr>ction,l>eoometh,,,,,inlOminwith 45·,.,condduration

Phcefetalse,jpdectn)(k

so nMlical

Gynecology

CASE I

History and phvsicatexaminetion

Discussion

mec.lcal 51

USMLESlepl:Obs!etrits/Gyneoology

52 ffieClical

• Hyph,.,rWo1Sl'Q,esonwe£moum

• AoliiLmgll """ml,"pposnorytor pJti,m only (do notu5u,lly need totreat>1'>:u ,lpJMer)

I . Oral,"liflJngilllher.pyto"ecur"'n!infroio"~

Norm<ll V'g",,1 Di<d1a'ge

• CI""r-Nhite"ginaldisch''lle ·pll<45

FiMKucaI 53

USMLEStepl:ObsltlriCS/GynKoIogy'

CASEl

Chiefcompi.Jint "lhavevagin.litching."

History and physical examination

DiflerentiaidiagnO'li5 C"",liJo.""Cti>iti. , \l.>""'-;al"gin,,,;,

, r,icho"","",v'cini,i,

Initial diagnostk plan Results

i. Urill.~-hCC,<>' ),pH"r .. g;".lflu;d

4. H"'g;ngdrop,salin<,.ndKQllp"'p

Treatmenlplan

54~1ca1

Cynecology

oscsscn

Final diagnosis

iMCIlcal 55

USMLEStepJ:Obstetrics/C\'IIHOlogy

CASEl

Chieicompiaint

-I haven't had my p<riod ,in« my baby w .. born 15 months ago,'

History and physical examination

Oifferentialdiagnosi5

• f'.os'''''<Y

• Es'rog<nd<fici<n<y

, Reprodudiv""rto",llowob.trtlction

f'.<gt<'ncy"h<mos,cornmon<>"oeor..."nda'yam<t>On-hea.ha.ibeenrul«lou"Now;l;s imp<manlkJiden'ii)<prngm.ron<Ol'eo'rog<t>d<lidon<y_

further diagnostjc plan LPr"1!",'eronech.ill<ngo">1 [progeoterone·in·oiIISOmsintromu",ularly)

Result Negatke("owi,hdrawalbl.«Iingl

Discussion

The mos' common """,eo or """ndory amenorrh<>, ,p,rt tTom progn.n<y, .... hotman,] .nd involveinadcq\1.«prog« .. ",ntO, .. ,rog<n.&"us<w:itbd"w,lbl«dingdidno,occ"r.ft<r admini",,,,tionofproges,crt,,,,,,,h'pfobl.mi.notbdof''''''l'u,]ul<um(ot,nol'Ulation). If anovul.tion ...... ""nnrm<dwilh."".i'i..,proge>leronechall.ng<h::>t.m·".srnt.n'isid<n'i.

r"""ionofrorr<etibl."" (hypolhyroidism"'hyp<'l'roIactinemi.).'b<nqding'h.pa'i<n'

wi,h<ycli<pn:>g«lin.'op n'.ndom<1ri.1hrp<'1']>Sia.CIomiph<n .... ould bcwcd for

indu<tiooofovul.'i<>nifp"l .. n<y .. ·.,.d .. iml.Th<nO::X< .. "l'irtlhi<GH<i<,oi ... n'ii)<if'h< ' ...... nrorlh.llOCkofwi!hd .. ..-.lhkcdingi,""rogendc6ci.,,<y_

56~1ca1

further diagnostic plan

C:"mgenandproge."eronedefid,nc'"b.vebc<n,uledout,Th"e"nohormonalexplanat,on for>ccofidary.rnmorrheo

Further fustcncinlormauon

Cornpleteobliterntionofuterinecavity

(hiefcompfaint Second")'ameno,,f1ea

mec.lcal 57

USMLE Step 1: ObstelricsJGynecoiogy

58 iiHKItcai

0."""",

CASE 4

Chielcornplejnt

Histcry end physkalexaminanon

D[fferenttaldtagnosis P'''lluancy,umpi;"",;,,",

Results N<gativ<

Further diegnostic plan

Results Endomctrialpolws

m&CIlcal 59

Assessment and treatment

Discussion

o Symplom,ind"d'ljr~~ime<lerbleeding_

I'

'!loSOflOgramsllOWl,mptygestationalsa(Or"Om;'bleptegnaor:Y.

o MJnagcmcmi,bJ"donPf"g<la"cyfiMi"i~

1:"""00

[""::::':':~::' "~"'" oc.,"oc'"OO" ,,,'" '" """'''0 "'."")

oSymr>mm,;ndud",bnormalt>'ee<finginbelweenregularmense5

o Sign.srnavbeat>seol . oHY'I"""OP'l"""salin'lOnO!","I",y,hO","iniraIJ!elineeodomelriaIPoiwo,,"t>"'"(oos

leIOITl)<Jm, ..

o M.n.gcmenl"":':_~roSOOJl"~~~_" 1

60 ~ical

GyaKoiozy

CASES

History and physkal examinatiOll

DifferentialdiagnO'iis

~~cal 61

USMLE$tepl:Obstetrics/G\'IIecology

Final diagnosis

62 meiHcaI

C\'1letology

CASE 6

Chief complaint 'Myb"""",c.",<,,ndlfedbloatedandmoody'

History and physical examination

Differential diagnosis

'Pregn,nC)'

• Premenstrual,yndromo

tJ<pre,,;on

Results

Symptnm'o,,",oOliyin tho "'[Ondhalfuft~c mon,""al '1'<10

Treatmenlplan M.,,,,"eallnenghavebempropo>cd;noDci,uoi,,,,<.allyeffec'ive

iiMHBcal 63

USMl£Stepl:O~~ology

Discussion

Final diagnosis

64 me&tcal

I Presn,n,)

• Symp!Omsin<lud,b,e"'ll."dernes"nd""ondJll'am",o~h ..

• Signs may indude enlarged UI~I\JS

• L,bo!iltOl)'lindin~"dodepositiveurin,or",","IH1CGlest 'Scmw"",showsi""'tMrlne~l""-

• M.l"gemerfis""""'M~~ncytindi~

i 1-

·SympJm;indodefueli"8'af~r15.nd~bullhekeyeltmenljo;,b<em:eol Cj<1.", .. rt.

·M'"'1lementmayindud.anlidepre<>llllSandp,ycholher,py

------------_j

m:iCHcaI 65

USMLEStep3:OIIstelJia/"1'y .. _"" .... "'-- _

CASE 7

Histcrv and pnysical examination

Differentiilldiilgnosis

Results

Discussion

2. Chlarny&azym<",,(immunofiuore,cence)

66~caI

Gynecology

Treatrnerllplan

iiMKIcaI 67

U5Ml£5tep3:0bstetrru./Gynerology

CASE a

History and physical examination

Prob.bl,.cutesalpingo_oophoriti,

68~lcaI

Treatmenlplan

L AdmillOlhchospil.J

Discussion

Acri'icnlqu'''i()ninthem,nagcmmtofpcivicinll,mm"",rycil'''mi,wh<lherto ho,pitali" Ih'V"i',,' forin"n,iv<mon'gcrnm,.Thcb"i<cri''';'''' il) preson,"oian ,b>«.S,.12),,·i d<n«ofdiffule.symmicinvalvernentwi,hhigbl<mp"""urol>l9CIIOl.lF]) •• l>domin01 Ku:J,ding·I<"cl<rn<".""Jlo'potie"'''''plic.pp''."n«.(J).nOU'p'';<n''""'ment failu". (4) p ..... "ce"f.nintr.'"tcrincdl:Vi«,'nd(5)un<e".indi.Bno.;~lndi""'ion,forinp.!ie",t",., ""n'in'hisp"i<n''''''higbf.....,randd''' .. <dWllC'''u"'.CtfoI<''norodoxitinccanb<uSC"d inrombinotionwithdoxycycline.Oinoiamycinlg<n"micinisa"oc«poab!<.:Il<rnativ<,oth.,., drugs""d is"SC"d;f'h.pa~."tispregrun,olaU.rgi<'op<ni<illjn.An""'pa';""'r<gimenfor ,hM<""',...,.",lyilliso ... ld<>X)'Cj'dinepl""intr",""<ubrtth,iuoncwi,hprobenecid.Saual I,"'n", •• hould.lsobet"",o:d;(,uitu"".",,,,,,itiv<forgonorrh<oor<l,bmydi ..

Other differential diagoo!ie,

• g_:~."<J"'i'diagnOs«l><megr.rhi(,'lIy."dism,",g<d"disru"""inG)'D<oology

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

• EoIdo",flri .. ;'-isu,u.IlydJron;c,.,h""dunocul<.l,i,diagnOO<dbyJ,p'''_''p)'.rtd <onb<m·""sed,u'll;GlUyormo:d;oily.

• C",hn Ju..u<;, often assoc;"o:d wiln Ji,,"'<' ,[\d vom;!ing. h;, ",,,,lly no'lo<al; ",d ,",h'p.Jv;,.D;'IjI!",i,isb),b.,iumcnemo.M,n'SO"""ti,u,,,,(lym.J;,,,I,.llhough oo"",lr<sec,;onmayocp",lr><m<d;n,.,.,,,,,,,,.

USMLESt.p3:0bslebi"'·ot""'''',. ... '''''''.,,'-- _

--------

·5ymplorTl5"ebiiaterallO'llle'-.lbdomitlili-pel'ui<:p,in.

-1

Pell'i'lnfl.mmatoryD~ea"

70 mec.cal

CASE 9

Hlstcry end physical exeminetlnn

.,onmm.lr.p,me"withinadequatecolposcopicev,]uation

iMilicai 11

USMl1Slepl:Obstetria/CiynecoLogy

"luamoLJS i""aepithdi.l lesi"n, then go to coip"scopy, \Vhhan unrriiabie patieLlt,gQdirectiy w."lp.,.o>pyanddirc<todbiop,ies.

Gynecology

CASE 10

Htstoryand physical examination

Initial diagnostic plan

Norm,ip<iv;C>1fU<1Urcs Ncg";vcfi.,,oOiarnydi •• nJgonocrh<o

Discussion

USMlIstepl:OIIstetria/Gyneoology

74_lcaI

Gynecology

• Ab'nig"<ond'tio"i"wI1~hei1dDmetrialglo"<i;."d;trorno,",,,,,"o"tsidelh.uIefIJ~

• Syrnproms are int.~"i!y and poin v.ith imort:oofSo,nd b"...,., movements ari~ngfrom "'ITi"!

"J<I,dh",iorlSfromirritationlromli>ebl()[)d,fj,dfmmlh,endome\rioln.su,

• Signsind"".Ir.eJ,"'~.liS1ir;findingsof"tero",crillligGmentnodul"ity,"d{uhJe-sa, ,dh",io",le.di"gto,li>:,d,lctf(lI'ei1edutml~

• Managementn"'Yl>em,di",l(oulpot,ntmiiOan'ige<ir.<)m'LJrgi,,,t(p,lvr.:d"""OLrtrequiriog tOlal.ixfominal hI'Ttrectorny,bila!eral ",lpingG'oophorecrorny)

• Di,gnosis~"'nli,medhistologir:al~ootll.hy;terectomj,peo::imen

• M,n,gemmti,hysr;"",romy.

(ConlinueJ)

~75

USMLE Step 3: Obstetrits/Gynetology

i~ ~~~~~~w~'=~~=·~) _

I Leiomyomo,

• ~en\lln'mooth fT1\J$(letumo" of Ill' ulerin, walL Thel mal enl"ReI,im rising I""," of "trogen

• SympIOJTl5moyu.,b:<:filormayirrdudepelvicp.linorbl«:dinRbeIWe,nreRUlarmenses

• Sign,jn<l"deaS\'lllmetrieJllyen',rged.li'm"ndn"ntenderuteru~

'SGno&/OpI1ymay>hOl'lsub>erosalintramur,Lor,ubmocos,llQ(Jfior\l

• 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_

~181

USMlISlepl:ObstetricsjC;)'IIeCology

CASE 13

Chief complaint

"I don't want 'ny more children

History and physical e~aminalion

Results

Results

Treatment plan

1. Di,;cu" ""riou, ,ltern"'"",;ndudingordl mntraceptiv< pill>.d;aphrogrrn,;ntrautcr inc devk<s,condom~andvase<'omy.

2. Counsel thep"tien' un the p<rm,ncn, ""U'C of uoe p<oc<du,",the operative r isks,and,he ch.nceoffailur«lin lOO)

Discussion

Final diagnosis

81~ical

,"yneco!ogy

CASE 14

History and physical eeminanon

Results

~~cal 83

USMLESlepl:Obstetria/Gynecology

5urs<ryiso~ ... ,ndio;al«1 ",1.ly lor qu.li'y-<>I-likdcl."ni"uio",_ Th •• ppr<»<h i •• "g;".j

o"".witb.vagin.llhymr<aomy.nd,n'.""".ndpostmorn:pair{IO'omn .... xcessi gin.1

muro"'.ndr"'pp..rum ... or·,igh'.n"'h<r<l>ic,"pporti.eligaotonts,includins'hc .,din.1

,ndu'aosa<rdlligame""I_ll<fot't.u'S<ry.h'"mon<repl."men'isusually.dmini".r<d,u imrrovcth<in'<gri'r~I'""""'l6u .. (sjY<no"IIy."dlor'opi"'llrJ

84 mec.lcal

CASE 15

Historyaod physical exemsancn

Differemialdiagn05is

Discussion

_leal 85

USMLESlepl:OlIstetriG/GY"K11logy

Discussion

86 me&lcal

All WOm.n gi .... hormo"," "",bo::m<n' lh<r.Pr'houid r.ceivt""n,inuou, ,'''_0 replace. mon'.\Vomrnwi'h.u'<ru<needrontinuou>progrnint<'p ..... '''u"'''pf''''''d ... n>g<n>ti",o l .. ionof.ndom",ri,lhyp<rpJasi • .oocan:inmno.

Finaldiagnosis

Mcnop'"..-ho,rnonereplacemm'

~k:a187

USMLiSttp1: Obsletrits/CYllKO!ogy

CASE 16

Chiefcomplainl "]'v,beenhk<dingfrommrvasi".."

History and physical examination

Differential diagnosis

• hdometri.lcard""m,

Initialdiagnosbcplan I. Eodom«ri;Jbio!"'y

R~sults

C",npl«hyperpl .. ",wi,hotypi.

Complexhyp<rpla!.i.with.typi,i •• p"'",.li"...",chang< and th", " posoibly.n indica,io" for try,1ao:tomy. M<dietl ''''''mon, with m'S<>1ml o<eI.I<,' high.dose prosest;". ts ,n .11",n.tiv<I<lhys«r«",myinP<'ti.".,whom.p<>oropm<tiverilk-Adil.tion.nd'"""'g<-i.not n"""",a'l·unlessth •• "dom'''i,lbiop'Y'p«im,nisnol"m,ide,ed.ciequ.",O .•. ,not.""ugh m't<ri.al,ub",i",d)

Results

Treatment plan I. Surgical staging

2. Expk" .. lo'l'lap.""omr,pomon •• I,,,nhi"8

3. TotaI.bd""'inalhystC"t<Ctom~wi'hbilal<TaI..JpiIl5'K">l'hor«tomy ~ . .'id«t<d pelvic."d p"""o,lic nod< dio.>roion

88~1

iii8iRcai 89

CASE 17

Chief complaint "Myabdomcnf«hbloa'ed,"dfull'

History and physical examination

Differential diagnosis

. Pc;macy""";'","""" • Ut<rinomasslfibro;d

In~ial diagnostic plan Results

LCh"",,,.,.y N'gative

GynlKoloO

L Tumord,bulking 3_Chemothmpy

Discussion

Finaldiagnosis

~191

USMLEStep3:0brtetl'itS/Gynemlogy

CASE 18

i-listory and physicai examination

Initial diagnostic plan Results

1.Vulvarbiop'Y

S'I"aon,,",hyp<rpiasiai,.b<nignlc:;ionwithoutm,lign"n1preJi>po'itiQn

Treatment plan

I. bluorinatedcortkO<1eroidcre.m

Pinaldlegnosis

92~1ca1

BONUS CASE A

(hieicomplaint

History and pnysiCilI examinatioo

Differential diagnosis

Male factor probkm

Results

~~d;)'CI' biph .. ,;c temp<,"'tife shift of

HQ£&1caI 93

U5Ml.E5lep3!ObsielricsjGynecology

Discussion

Finilldiagnusis

94 iii8itical

BONUS CASE B

Chief complaint "l'mgottinghairie,l"

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<

Withinnormalf.m.I.,o.rrg<

.l,5<,umli-hydwxYI''''Il<'"ron.

W;thionorm1lrans<

Assessment

tdiop01hiohai,r"nkl,sensi'iviry

Trealmentplan

Th<' .... 'mrn'ofchokeis.pironobctoll< •• pol .... "m- • .,.,ingdiurnic.I15m«b.ni.mof a<:'ion .. ona.nti-."""'5"n"'''''roid.f;r.;1.i'lsan.ndrogcn.J'O(.p'o,bIoc ....... haiso5llp pr ..... hai,follicIe5-am!u" .... "'ym.oonversionof.ndro>1on«liono.nd""'ost.ro"",o ,h<mor<potentdihyd,ot<>,osl<ron •.

Discussion

ii*kaI 95

U5MLE5tepl:ObsteiricsjGynl!<ulogy

flnaldiagno>is

BONUS CASE C

(hi~complaint

·[· ... u ...... h'd.p<ri<Wl·

History and physicill exominaton

DiffertntialdiilgnO!iis

. Mull<ri.nag<D<>k

. An<irogonin><n.ilivil}'

tn~ial diagnostic plan I. Pd .. ic'''''''l!"m

Results

Confirm, uto,u.o "bo,nt: ovari .. pres,n' Norm,1 r"",,I<I."e~

Asses~ent

Treatment pian

Discussion

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.

If.hoh1dnUI'"~i<:o,oxiU • ..,.hair.th,di"S"o';'W<luldbe,c",pl",a"d"'geni",,,",irivily.Thi, would bc"mfirmedbyhigh male"",o",ron,]ov<is.nd46,xYkaryolyp<.JnguiruJ",,,esnced (ol><r<On"V<db<a." .. of~lOhighcaJl<errisk.rnd."rog<nth·"pr.nouldbel>egunaIld.n«>'''gin .... ,,<d,No prog<Slini,noeded.

!fb ... _~."","t.it-...uJdmean""h>dJow<5lrogmI<Y<ls.Th"<oWdl><from .. tb .. ~ offQUid .. ..;'hinhrrgonad<Olladtof"imw.rionofthrfQUido •• which.",I""""'L'l'he""rkup