Tuesday, April 5, 2016

Step 2 CS: Amenorrhea

I am just trying to set a sequence of questions to ask in the exam, tests to order and examination to do so that I am not all over the place in the exam.

So here's what I am going to do if a case of amenorrhea shows up - Ask about general menstrual history and then go to symptoms specific for differentials:

Menstrual history: How long do they last, how many pads, menarche, LMP, cramps with periods, vaginal discharge, blahblahblah.

Pregnancy: Sexual activity, birth control, previous pregnancies.
Workup: Urine HCG

Hyperprolactinemia symptoms: Galactorrhea, oligomenorrhea leading to amennorrhea, infertility, anti-depressant use, changes in vision.
Workup: Prolactin, TSH.

Hyperandrogenic symptoms suggestive of PCOS: Skin changes (acne), hair and voice changes.

Symptoms suggestive of premature ovarian failure: Hot flashes, vaginal dryness, itching.

Secondary amenorrhea: Eating disorders

Workup: FSH, LH

For examination:
Eye exam and visual field: "EOMI, visual fields full to confrontation, no lid lag, diplopia."
Ask patient to swallow: "No thyromegaly"
Check DTR:  "Normal DTR bilaterally"
Optional: Auscultate heart, lungs. Palpate abdomen.

Mention need for pelvic exam and breast exam.

Mnemonic for differentials: PPPPAT
Pregnancy
Prolactinoma
Pause (Premature menopause)
PCOS
Anorexia
Thyroid

Extra tip:
History findings suggestive of pregnancy -
Amenorrhea
Sexually active (I didn't know you could write this xD)
Previously successful pregnancy

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Here's my sample note I wrote in 10 minutes after practicing the case from first aid:

History :
36 yo F c/o amenorrhea since 3 months. Her periods last for 5-6 days and she usually one pad per
day since the past one year. Normally her periods last for 4-5 days and she uses 2-3 pads per day.
Also complaints of galactorrhea since a few days. Denies visual field loss.
C/o hirsutism, weight gain. Denies voice changes, acne.
Denies cold or heat intolerance, diarrhea or constipation.
Denies hot flashes, vaginal dryness, itching or discharge.

OBGYN: Menarche at age 14, had one child 10 years ago, NVFTD, child is alive and well. Sexually
active with husband, uses pills since 8 years.

PMH / PSH / FH: None
Medications: None
Allergies: NKDA
SH: Denies EtOH, smoking, drugs

Physical Examination :

Pt is NAD
VS: WNL
HEENT: PERRLA, EOMI, no nystagmus, lid lag, drooping eyelids.
Neck: No thryomegaly.
Extremities: No edema feet.

Diagnosis 1 :
Pregnancy
History Findings
1) Amenorrhea
2) Previous successful pregnancy

Diagnosis 2 :
PCOS
History Findings
1) Weight gain
2) Hirsutism
3) Amenorrhea

Diagnosis 3 :
Prolactinoma
History Findings
1) Oligomenorrhea followed by
Amenorrhea
2) Galactorrhea

Diagnostic Study/Studies - Labs
1) Breast and pelvic exam
2) Urine HCG
3) Prolactin / TSH
4) FSH / LH

Feedback from my friend:
The only thing missing is past history is details of menses - like were they regular before, irregular etc. The supporting point here for pregnancy is also sexually active.

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