OB/GYN H&P #1 8/4/20
Chief complaint: Lower abdominal pain and vaginal bleed x 2 weeks.
HPI: Mrs. A is a 31 y/o G3P2002 Hispanic female with PMHx of subarachnoid hemorrhage, anxiety and depression who presented to the ED of Woodhull Hospital on 8/3 with complaints of worsening abdominal pain and vaginal bleeding x 2 weeks. Pt described a sharp, constant, 10/10 pain located in the lower quadrants and radiating to the right ribs with no alleviating or worsening factors. Pt also reported a mild vaginal bleeding. Pt had an IUD placed on 7/9/2020. She denies having her menstrual period since the IUD placement. On 7/31/, Pt presented to the ED with similar complaints and was diagnosed with an UTI and pregnant (B-Hcg of 3,438). Pt was advised to follow-up with the clinic in 2 days. On 8/2, B-Hcg was repeated and increased to 5,625. On 8/3, pt presented with worsening symptoms and was found to have small collection outside of the uterus on pelvic ultrasound. On 8/4, pt was taken for exploratory laparotomy with right salpingectomy-oophorectomy due hemoperitoneum and probable ectopic pregnancy.
Currently, pt is POD #0, A&O x3 and afebrile with complaint of mild pain at the incision site. On inspection, incision dressing is clean, dry and intact. JP drain noted with 50cc of dark blood and urinary catheter with 300cc. Pt denies N/V/D, dizziness, SOB, chest pain or palpitations.
Past Medical History:
Present illnesses – Anxiety and depression
Past medical illnesses –Subarachnoid hemorrhage, 8/14/2019 Hospitalized – (see PSHx).
Immunizations -unknown status.
Past Surgical History: C-section, macrosomic baby, shock due to difficult removal of placenta-2012 Cerebral angiogram
Lipoma Resection- Left flank-Ecuador
Medications:
Clonazepam 0.5 mg BID PO Sertraline 100mg daily PO Acetaminophen 650 mg PO.Allergies:
No allergies
Family History:
Father: myocardial infarction, HTN, hyperlipidemia- aliveMother:diabetes mellitus, migraine- alive
Social History:
Mrs. A is a housekeeper who lives with her husband and 2 kids. Pt admits social drinking and denies smoking or use of recreational drugs.
ROS:
Gen –Denies loss of appetite, fatigue, weight loss, fever, chills or night sweats.
Skin, hair, nails—Denies change in texture, dryness, pruritus, diaphoresis or change in hair distribution.
Head—Denies headache, vertigo, light-headedness or recent head trauma
Eyes—Denies blurring vision, photophobia, pruritus, dryness, diplopia, scotoma, lacrimation, halos or fatigue with use of eyes. Use reading glasses. Unknown last eye exam
Ears—Denies hearing loss, use of hearing aids, pain, discharge or tinnitus.Nose/sinuses—Denies epistaxis, nose discharge or obstruction.
Mouth/throat—Denies bleeding gums, sore tongue, sore throat, mouth ulcers, or changes in voice. Unknown last dental exam.
Neck—Denies localized swelling, lumps, stiffness or decreased range of motion
Pulmonary – Denies dyspnea, cough, orthopnea, dyspnea, hemoptysis or wheezing.CV—Denies HTN, chest pain, peripheral edema, syncope, palpitation, irregular beats and known heart murmur.
GI—Admits sharp, constant, non-radiating, 4/10 pain at the incision site. Due to recent surgery, pt hasn’t had bowel movements. Denies diarrhea, nausea, vomiting, dysphagia, hematemesis, hemorrhoids, or heartburn. Pt is not due for colonoscopy.
GU— Pt has an urinary catheter. On 7/31, pt was experiencing dysuria and hematuria. Currently, unaware of frequency, nocturia, urgency, oliguria, dysuria, polyuria, hesitancy, or dribbling.
Menstrual/Obstetrical –LMP 5/15/2020. Pt got an IUD on 7/9/2020. She denies having menstrual period after IUD placement. Before IUD, periods were regular lasting 3 days with normal flow. Pt admits mildly vaginal bleeding for the past 2 weeks. Denies postcoidal bleeding, dyspareunia or hx of STDs. Pt is G3P2002 with 3 pregnancy, 2 deliveries (1 vaginal and 1 c-section) and 1 ectopic pregnancy. C- section complicated by macrosomic baby and difficult removal of placenta which led to a shock. After c-section, pt had difficulty conceiving.
Nervous—A&O x3. Denies seizures, headache, loss of consciousness, numbness, paresthesias, dysesthesias, ataxia, loss of strength and change in cognition or memory.Musculoskeletal—Denies muscle pain, swelling, redness, deformity of muscles/ joints or arthritis.
Peripheral— Denies intermittent claudication, coldness, varicose veins, peripheral edema and color change.
Hematological— Denies blood transfusion, anemia, easy bruising, lymph node enlargement or Hx of DVT/PE.
Endocrine—Denies diaphoresis, polydipsia, polyphagia, heat or cold intolerance, goiter and hirsutism.
Psychiatric— Pt admits being currently treated for anxiety and depression. Patient denies feeling depressed or having suicidal ideations at the moment.
Vital Signs:T 98.5 F, HR 78 bpm, BP 125/76, RR 18, SpO2 98% room air, BMI 30.0
Physical Exam:
Gen– AOx3, mildly distressed, well-developed and appears his stated age.
Skin: warm & moist, good turgor, non-icteric, no visible lesions or scars.
Nails: no signs of clubbing, lesions, paronychia, capillary refill <2 second.
Hair: Thick hair, evenly distributed with no signs of erythema or dryness in the scalp.
Head: No specific facies. Normocephalic, non-tender to palpation with no signs of swelling or trauma.
Ear:Intact tympanic membrane with undisturbed cone of light bilaterally. No lesions or erythema in the auditory canal bilaterally. Whispering test unremarkable bilaterally.
Eyes: PERRLA, full visual fields and intact EOM. White sclera and pink conjunctiva bilaterally with no nystagmus. Visual acuity 20/20 b/l. Unremarkable optic disc, no hemorrhage or exudates bilaterally on fundoscopy.
Mouth: pink and moist mucosa with no masses, thrush or lesions. No signs of tonsil exudate or enlargement. Uvula pink with no signs of edema, deviation or lesion.
Trachea/thyroid: midline and non-tender to palpation. Non-palpable nodule or bruit on auscultation. No lymphadenopathy.
Lungs: Clear to auscultation bilaterally anteriorly. No rales, rhonchi or wheezing on auscultation. No signs of labored breathing. Unremarkable egophony and tactile fremitus.
Breast:symmetric, no dimpling, no masses, nipples without discharge b/l. No axillary nodes palpable.
Cardiac: Normal S1/S2 and RRR. No murmur, JVD or carotid bruits noticed.
Abdomen: Mildly distended abdomen. Clean, dry and intact incision dressing. JP drain noted with 50cc of dark blood. Few striae with no sign of masses. Bowel sounds absent in upper quadrants. Unable to assess lower quadrants due to incision dressing. Mildly tenderness to palpation in upper/mid quadrants. No guarding or rebound tenderness. No signs of liver or spleen enlargement.
GU: Normal pubic hair distribution. No masses or lesions on labias or vaginal vestibule. No signs of inflammation, discharge or erythema on vaginal mucosa or cervix. No cervical motion tenderness. Adnexa without masses or tenderness.
Rectal:. No lesions, fissures, hemorrhoids or stool in rectal vault. Good sphincter tone. Negative guaiac.
Extremities:Full active ROM in upper extremities bilaterally. Unable to assess lower extremities due to surgical incision. 2+ pulses in upper and lower extremities. No sign of edema, cyanosis or muscle atrophy. No calf tenderness.
Neurology: A&Ox 3. Intact finger to nose test b/l. Intact sensation, and proprioception in UE and LE bilaterally. Unable to assess gait and Romberg test. Muscle strength 5/5 in UE. Unable to assess muscle strength in LE. Cranial intact 2-12. Biceps, ankles and triceps reflexes 2+ bilaterally.
DDX:
Ectopic pregnancy ,Ovarian torsion, Ovarian cyst rupture, Uterus rupture from IUD Appendicitis
Assessment/plan: Mrs. A is a 31 y/o Hispanic female POD #0 s/p right salpingectomy-oophorectomy due hemoperitoneum and probable ectopic pregnancy currently stable.
-Order CBC and b-HcG
-Continue PostOp care
-Monitor Urinary output
-Monitor JP drainage
-Continue wound care
-Give methotrexate
-Give Tylenol as needed.
Article Summary
Residual microcalcifications after neoadjuvant chemotherapy for locally advanced breast cancer: comparison of the accuracies of mammography and MRI in predicting pathological residual tumor. An YY, Kim SH, Kang BJ.World J Surg Oncol. 2017 Nov 6;15(1):198. doi: 10.1186/s12957-017-1263-8. PMID: 29110671 Free PMC article.Clinical Trial.
● This is a prospective cohort study published in 2017. Journal is currently indexed by Medline.
● The purpose of this study was to determine the relationship between residual microcalcifications found on mammograms with pathological results as well as to compare the accuracy of MRI and mammogram in predicting the size of residual tumor studied by pathology.
● A database of 59 patients with locally advanced breast cancer with stage II or II and who were treated with neoadjuvant chemotherapy between April 2015 and April 2016 was created.
● All 59 patients received four cycles of doxorubicin and cyclo-phosphamide or six cycles of doxorubicin and docetaxel. In patients with positive HER2, Herceptin was added to the regimen. Patients were assessed with mammogram and MRI after chemotherapy and before performing surgery.
● Of the 59 patients, 29 patients were identified with suspicious malignant microcalcifications within the tumor area based on mammograms performed before and after chemotherapy. The remaining 27 patients not showing microcalcifications were excluded from the study.
● Mammogram and MRI results were reviewed by two radiologists with experience on breast imaging of 6 and 14 years. These radiologists were also blinded to histopathological, clinical and imaging results of the patients. A pathologist with 17 years of experience analyzed the surgical specimens.
Results
● Four patients achieved pathological complete response and twenty-five had residual malignancy after surgery and neoadjuvant chemotherapy.
● Residual microcalcifications associated with residual malignancy were found in 55.2% of the patients (n=16) and benign in 44.8% of patients (n=13) invasive carcinoma or DCIS.
● Fine pleomorphic microcalcifications were correlated with residual malignancy while amorphous microcalcifications were associated with benign microcalcifications.
● In terms of accuracy of size assessed with MRI or mammogram, both were not adequate enough for residual calcifications after treatment with neoadjuvant chemotherapy. The size of residual tumor with remaining microcalcification is overestimated with mammogram and underestimated with MRI.
● The accuracy of these imaging modalities is affected by the tumor receptor status. The concurrency size between the pathological and MRI/mammogram results increases with ER positive and HER2 negative tumors and decreases with tumor ER negative.
Article. PDF 12957_2017_Article_1263
End of Rotation Self-reflection: RT4: OB/GYN
- How could the knowledge I’ve gained here be applicable in other rotations/disciplines? In this rotation, I had the opportunity to practice pap smear, chlamydia and gonorrhea cervical swabs and pelvic exams. I also had the chance to practice history taking pertinent to obstetric and gyn patients as well as to provide education in relation to women health and precautions during pregnancy. After this rotation, I now have a better understanding of contraceptive management and their pros/cons to a woman’s health, lifestyle and daily routine. In addition, I got good exposure to certain common gyn/ob diseases and procedures such as IUD insertion/ removal, ectopic pregnancy, candida/yeast, bacterial vaginosis, trichomoniasis infections, miscarriage and abnormal uterine bleeding; I feel now that can better identify and treat these conditions. These are skills that can be applicable in future rotations like emergency medicine or family medicine if a patient presents with a gyn or ob complaint.
- What did you learn about yourself during this 4-week rotation? During this 4-week rotation, it was reassuring that I am still interested in internal medicine or emergency medicine. Obstetrics is a beautiful speciality, particularly the delivery of the neonate and observing the bonding between the mother and her baby. Although as a female I can relate to and understand general women’s concerns, I still find more enjoyment in practicing general medicine. Aside from this, I learned that I do a good job at educating patients about their condition and breaking it down into simple terms, so that it is easier for them to understand their condition.
- Exposure to new techniques or treatment strategies – how did that go?In the clinic, I worked with different doctors and midwives that I have different styles. There was one doctor who had a different technique for the bimanual exam. She first introduced the index finger in the vagina applying downward pressure to appreciate any pain and then upward pressure to introduce the middle finger. After having both fingers in the vertical position, she turned them to horizontal position to palpate for the adnexa. She strongly emphasized doing these steps, particularly applying downward pressure first with the index finger and then inserting the middle finger. After observing her a couple times, the bimanual exam went well by doing this technique.
Evaluation reflection In the first site evaluation, I presented a 31 y/o Hispanic female with PMHx of subarachnoid hemorrhage and IUD in place who presented with complaints of worsening abdominal pain and vaginal bleeding x 2 weeks. Pt was found to be pregnant and was taken for exploratory laparotomy with right salpingectomy-oophorectomy due hemoperitoneum and ectopic pregnancy. For my second site evaluation, I presented a 65 y/o Hispanic female with PMHx of DCIS right lumpectomy (treated with radiation and tamoxifen) who presented to the clinic for annual gyn examination. Overall, both evaluations went well; however, I felt that my performance was better during the second evaluation. It was better organized and focused. For the second evaluation, I presented an article about residual microcalcification in women with breast cancer treated with adjuvant chemotherapy. We both have a good discussion about the article results. This article found that pleomorphic microcalcifications were correlated with residual malignancy while amorphous microcalcifications were associated with benign microcalcifications and that accuracy of microcalcification size between the pathological and MRI/mammogram results increases with ER positive and HER2 negative tumors and decreases with tumor ER negative.
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