First Aid for the USMLE Step 2 CS

Section 3. Minicases

Vaginal Bleeding

Key History

Pre- vs. postmenopausal status, duration, amount; menstrual history and relation to last menstrual period; associated discharge, pelvic or abdominal pain, or urinary symptoms; trauma; medications (especially blood thinners, contraceptives); history of easy bleeding or bruising; history of abnormal Pap smears.

Key Physical Exam

Vital signs; abdominal exam; complete pelvic exam.

VAGINAL BLEEDING (cant'd)

Presentation

Differential

Workup

■ 17 yo F presents with prolonged, excessive menstrual bleeding occurring irregularly within the past 6 months.

Dysfunctional uterine bleeding

Coagulation disorder (eg, von Willebrand’s disease, hemophilia)

Cervical cancer

Molar pregnancy

Hypothyroidism

Diabetes mellitus

Urine hCG

Pelvic exam

Cervical culture

Pap smear

CBC

ESR

Glucose

PT/PTT

LH/FSH, TSH, prolactin

U/S—pelvis

■ 61 yo obese F presents with profuse vaginal bleeding for the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.

Endometrial cancer

Cervical cancer

Atrophic endometrium

Endometrial hyperplasia

Endometrial polyps

Atrophic vaginitis

Pelvic exam

Pap smear

Endometrial biopsy

Endometrial curettage

U/S—pelvis

Colposcopy

Hysteroscopy

■ 45 yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.

Cervical cancer

Endometrial cancer

Cervical polyp

Cervicitis

Trauma (eg, cervical

laceration)

Pelvic exam

Pap smear

Colposcopy and biopsy

HPV testing

Endometrial biopsy

■ 28 yo F who is 8 weeks pregnant presents with lower abdominal pain and vaginal bleeding.

Spontaneous abortion

Ectopic pregnancy

Molar pregnancy

Urine hCG

Quantitative serum hCG

U/S—abdomen/pelvis

Pelvic exam

CBC

PT/PTT

■ 32 yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was 5 weeks ago. She has a history of pelvic inflammatory disease and unprotected intercourse.

Ectopic pregnancy

Ruptured ovarian cyst Ovarian torsion Pelvic inflammatory disease

Urine hCG

Quantitative serum hCG

U/S—abdomen/pelvis

Pelvic exam

Cervical cultures

 

Vaginal Discharge

Key History

Amount, color, consistency, odor, duration; associated vaginal burning, pain, or pruritus; recent sexual activity; onset of last menstrual period; use of contraceptives, tampons, and douches; history of similar symptoms; history of STDs.

Key Physical Exam

Vital signs; abdominal exam; complete pelvic exam.

Presentation

Differential

Workup

■ 28 yo F presents with a thin, grayish-white, foulsmelling vaginal discharge.

Bacterial vaginosis

Vaginitis—candidal

Vaginitis—trichomonal

Cervicitis (chlamydia,

gonorrhea)

Pelvic exam

Wet mount, KOH prep, “whiff test”

pH of vaginal fluid

Cervical cultures

■ 30 yo F presents with a thick, white, cottage cheeselike, odorless vaginal discharge and vaginal itching.

Vaginitis—candidal

Bacterial vaginosis

Vaginitis—trichomonal

Pelvic exam

Wet mount, KOH prep, “whiff test”

pH of vaginal fluid

Cervical cultures

■ 35 yo F presents with a malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.

Vaginitis—trichomonal

Vaginitis—candidal

Bacterial vaginosis

Cervicitis (chlamydia,

gonorrhea)

Pelvic exam

Wet mount, KOH prep, “whiff test”

pH of vaginal fluid

Cervical cultures





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