GameBoy 1–600 — Summaries

 

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0001. A 40-year-old man with a history of recurrent painful attacks affecting the right big toe, was diagnosed with gout and started on allopurinol. He is also a known case of psoriasis for several years. He presented to the clinic with recurrent joint pain affecting the right big toe, left ankle, and bilateral knees. He is using allopurinol regularly as prescribed but has no improvement in his joint pain. Examinations revealed he has active arthritis at the left ankle and knee joints bilaterally (see lab results). = Psoriatic arthritis

0002. A 28-year-old woman with systemic lupus erythematosus for 2 years on hydroxychloroquine 200 mg/day, prednisone 5 mg/day, and azathioprine 100 mg/day presented to the Emergency Room with sudden onset of lower limb weakness and urinary incontinence. Examination revealed she has paraplegia and hyperreflexia (see lab results). = Lumbar puncture, MRI spinal cord

0003. A 50-year-old man is complaining of pain affecting the wrist joints bilaterally, second and third proximal interphalangeal joints, and right knee joint for the last 4 months. His examination revealed active arthritis at both wrists and second and third proximal interphalangeal joints (see lab results). = Methotrexate, hydroxychloroquine, and prednisone

0004. A 30-year-old woman with systemic lupus erythematosus is evaluated for right hip pain that started 3 weeks ago and occurs at night and with walking. Her current medications are azathioprine, hydroxychloroquine, prednisolone, and lisinopril for the last 5 years. Her examination was normal except for pain on internal rotation of the right hip. Laboratory tests including pelvic and left hip radiographs were normal. = Avascular necrosis affecting right hip

0005. A 60-year-old man complaining of right knee pain for several years that has increased over the last few months. He also has noticed frequent knee clicks. A diagnosis of osteoarthritis is suspected. = No further investigation

0006. A 52-year-old man with rheumatoid arthritis for 12 years. His current treatment consists of methotrexate 15 mg weekly and adalimumab 40 mg/2 weeks. He presented to the clinic complaining of fever and shortness of breath for 1 week. His chest examination revealed coarse crackles over the lower part of the right lung (see lab results). = Hold his current treatment and start antibiotics

0007. A 30-year-old man presented to the Emergency Department with an acute monoarthritis where joint aspiration was performed. Based on the presence of crystals in the synovial fluid, he was diagnosed with gout. = Needle-shaped, negatively birefringent

0008. A 30-year-old woman with a diagnosis of systemic lupus erythematosus who was maintained on mycophenolate mofetil 1 gm/day, hydroxychloroquine 200 mg/day, and prednisone 5 mg/day for the last 1 year. She has had inactive disease for more than 6 months. She is planning to get pregnant (see lab results). = Discontinue mycophenolate mofetil and start azathioprine

0009. A 61-year-old woman is evaluated for a left pulmonary nodule that was discovered incidentally 2 months ago. She is currently asymptomatic and has not had shortness of breath, fever, chills, weight loss, or night sweats. Medical history is otherwise unremarkable, and she takes no medications. She never smoked. Examination revealed no cervical or supraclavicular lymphadenopathy, and the lungs are clear to auscultation (see report). CT scan chest: Showed an 8 mm left lung nodule. = Observation and regular follow-up

0010. A 63-year-old woman presented with exertional dyspnea for 8 months. She was diagnosed with COPD 3 years ago and has had 4 exacerbations in the last year. She completed pulmonary rehabilitation and quit smoking 2 years ago. Medications include long-acting B2 agonist, inhaled glucocorticoid, roflumilast, and albuterol as needed. Examination revealed no jugular venous distention; decreased breath sounds, a loud pulmonary component of S1 (see lab results and reports). Chest radiograph: Normal. Echocardiogram: Ejection fraction of 60%, no valvular or wall motion abnormalities, and estimated mean pulmonary artery pressure is 55 mmHg. = Long-term oxygen therapy

0011. A 58-year-old woman presented to the medical clinic complaining of daily wheezing and breathlessness during allergy season. These episodes of wheezing have limited her activities several times a week. She has a long history of seasonal allergies in the form of itchy eyes and runny nose. No other medical history. Medications include loratadine as needed, and antihistamine eye drops. Examination revealed watery eyes with conjunctival irritation, expiratory wheezing, and normal cardiac examination (see reports). Chest radiograph: Unremarkable. Spirometry: FEV1 of 74% of predicted, which improved by 18% with a bronchodilator. = Add a low-dose inhaled glucocorticoid and long-acting B2 agonist

0012. A 71-year-old man is evaluated after a recent hospitalization 10 days ago for pneumonia and was discharged with a 10-day course of appropriate antibiotics. For the past 5 days, he has had a low-grade fever and increased shortness of breath. Pulmonary examination reveals decreased fremitus, dullness to percussion, and decreased breath sounds over the lower third of the right hemithorax (see lab results and report). Chest radiograph: Moderate right-sided pleural effusion. = Small-bore pleural drain and piperacillin-tazobactam

0013. A 20-year-old man is evaluated for a 6-month history of chest and throat tightness, acute episodes of stridor, and a prolonged wheeze that occur during his college basketball practice. He has a history of moderate persistent asthma, which is controlled. He takes a short-acting B2 agonist inhaler as needed, but this does not relieve his symptoms. In addition to a low-dose inhaled glucocorticoid and a long-acting inhaled B2 agonist, he otherwise feels well. Medical history is otherwise unremarkable. Examination reveals normal vital signs and unremarkable systemic examination (see reports). Chest radiograph: Normal. Spirometry: No evidence of obstruction. = Otolaryngology evaluation

0014. A 33-year-old man presented with shortness of breath, fatigue, and nighttime cough. He has been working in a car repair shop for the past 1 year and notes that his symptoms began about 8 months ago. He believes his symptoms are associated with his workdays. He is being evaluated after several days off from work and currently has no symptoms or medical concerns. He has an unremarkable medical history and takes no medications. He has never smoked. Physical examination is unremarkable. A chest radiograph and spirometry results are normal. = Repeat spirometry after workplace exposure

0015. A 49-year-old woman is evaluated for a 4-month history of dry cough, which began 4 months ago when she noted a paroxysmal onset of persistent coughing spells that make it difficult to carry on a conversation. She was initially diagnosed with allergic rhinitis and was started on a glucocorticoid nasal inhaler with no improvement. Medical history is otherwise unremarkable except for a history of dust allergies. Examination revealed normal vital signs, slight nasal congestion, and dry cough are noted during the examination. Cardiovascular, pulmonary, and abdominal examination findings are unremarkable (see reports). Chest radiograph: Normal. Spirometry: Slightly reduced FEV/FVC ratio of 70% which increased after bronchodilator challenge by 20%. = Methacholine challenge testing

0016. A 57-year-old man is evaluated for chronic cough, occasional wheezing, and exertional dyspnea while walking. Medical history includes an episode of bronchitis, for which he underwent outpatient treatment 8 months ago. He has a 20-pack-year smoking history. Examination revealed normal vital signs, mildly decreased breath sounds throughout both lungs, and scattered expiratory wheezes bilaterally. Spirometry shows an FEV1 of 75% of predicted and a post-bronchodilator FEV/FVC ratio of 68%. His modified Medical Research Council (mMRC) symptom score is 2. = Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation

0017. A 42-year-old woman presented to the clinic for follow-up of a 7-month history of chronic, nonproductive cough. She was recently diagnosed with cough-variant asthma after a methacholine challenge test. She was started on inhaled fluticasone and as-needed albuterol 2 months ago. Her cough initially improved; however, her symptoms have not fully resolved and are worsened at times, most notably when she lies down. She also noted that mild hoarseness occasionally accompanies her cough, especially when she wakes up in the morning. Examination revealed a dry cough with frequent throat clearing. The chest was clear with no wheezing. = Add a proton pump inhibitor

0018. A 17-year-old man presented to the Emergency Department with severe asthma exacerbation that began 12 hours ago. He is on an albuterol inhaler and a long-acting glucocorticoid at home without improvement. He was hospitalized and intubated 2 years ago. Examination revealed respiratory distress with diffuse expiratory wheezes. After 1 hour of systemic glucocorticoid and B2 agonist nebulizer, he still appeared in respiratory distress (see lab results and report). Chest X-ray: Hyperinflated lungs. = Admit to the ICU

0019. A 63-year-old man was evaluated in the Emergency Room for 1 week of progressive shortness of breath and found to have right pleural effusion on chest X-ray. Aspiration yielded a clear transudative fluid. = Heart failure

0020. A 24-year-old woman is reviewed in the Asthma Clinic. She currently uses a salbutamol inhaler 100 mcg prn combined with a beclometasone dipropionate inhaler 400 mcg bd. Despite this, she is having frequent exacerbations of her asthma that required frequent courses of prednisolone and hospitalization three times in the last 6 months. = Add long-acting B2 agonist (Salmeterol)

0021. A 63-year-old woman is in the COPD clinic for frequent exacerbations, despite being maintained on a salbutamol inhaler as required and a tiotropium inhaler regularly. She was diagnosed with COPD three years ago and recently quit smoking. Her latest FEV1 was 39% of predicted. = Combined salmeterol + fluticasone inhaler

0022. A 69-year-old smoker presents with a 3-week history of worsening breathlessness. Examination revealed normal vital signs and decreased breathing sounds over the lower left zone (see reports). Chest X-ray: Large left-sided pleural effusion. Pleural tapping: Pending result. = Effusion LDH level greater than 2/3rds the upper limit of serum LDH

0023. A 33-year-old man with a history of severe asthma is admitted to the Emergency Department with an asthma attack. He received high-flow oxygen and nebulized salbutamol. He is unable to complete sentences, has bilateral expiratory wheeze, and is unable to perform a peak flow reading. He was immediately given intravenous hydrocortisone and nebulized salbutamol continuously. After 10 minutes, there is no improvement, and intravenous magnesium sulfate was given. His condition continues to deteriorate (see lab results). = Intubation and mechanical ventilation

0024. A 34-year-old woman with a history of asthma and allergic rhinitis has been discharged from the hospital 2 weeks ago following an acute exacerbation of bronchial asthma and reports generally poor control with a persistent nighttime cough and exertional wheeze. Her current asthma therapy is salbutamol inhaler 100 mcg prn, beclometasone dipropionate inhaler 800 mcg bd, and salmeterol 50 mcg bd. = Leukotriene receptor antagonist

0025. A 33-year-old woman has been assessed in the Emergency Department with an acute exacerbation of asthma. = Peak flow of 30% best or predicted

0026. A 26-year-old man is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulized salbutamol, ipratropium bromide nebulizers, and IV hydrocortisone. Despite initial treatment, there is no improvement. Examination reveals that he is in respiratory distress, cannot complete full sentences, and has bilateral expiratory wheezing. = Magnesium sulfate

0027. A 70-year-old man known to have chronic obstructive pulmonary disease (COPD). Examination revealed evidence of cor pulmonale with a significant degree of lower limb edema. His FEV1 is 40% (see lab result). = Long-term oxygen therapy

0028. A 55-year-old man is evaluated for an 18-month history of intermittent, nonproductive chronic cough, and dyspnea with exertion. No history of fever, chest pain, heartburn, loss of appetite, or weight loss. He has smoked 1 pack daily for the last 30 years. His medical history is otherwise unremarkable, and he takes no medications. Examination revealed he is comfortable, no jugular venous distention, normal heart sounds, no murmur, clear lungs, and no lower limb edema. A chest radiograph and electrocardiogram are normal. = Spirometry

0029. A 79-year-old man is evaluated in follow-up for a 2 mm solitary pulmonary nodule, which was incidentally discovered on imaging for chest pain 4 years ago. Follow-up chest CT was obtained at 1, 2, and 3-year intervals, and the pulmonary nodule appears unchanged. He feels well and does not have any respiratory or constitutional symptoms. He never smokes. Examination revealed normal vital signs and cardiopulmonary examination. = No further imaging is necessary

0030. A 68-year-old woman is evaluated in follow-up after a 5 mm pulmonary nodule was discovered on chest imaging obtained 9 months ago. She feels well and has not had shortness of breath, cough, hemoptysis, weight loss, or chest pain. She has a 50-pack-year smoking history and is a recurrent smoker. Examination revealed normal vital signs, no cervical or supraclavicular lymphadenopathy, and clear lungs to auscultation bilaterally (see report). Repeated chest CT: Interval increase in the size of the nodule, now measuring 10.5 mm in diameter, and no evidence of mediastinal or hilar lymphadenopathy. = Refer for thoracic surgery

0031. A 69-year-old man complains of shortness of breath and weight loss for the last 6 months. He has a 40-pack-year smoking history and no TB or HIV risk factors (see reports). Chest X-ray: A large left-sided pleural effusion. Thoracentesis: 1,500 mL of bloody fluid that is strongly exudative by Light’s criteria. = CT chest with contrast

0032. A 55-year-old woman is referred to the clinic because of a 1 cm solitary nodule with sharp borders in the right lung. The nodule was detected on an abdominal CT performed to evaluate abdominal pain. She does not have any respiratory complaints. She smoked 20 cigarettes per day for 10 years but managed to stop smoking 20 years ago. = Follow-up CT in 3-6 months

0033. A 71-year-old man is admitted to the hospital because of high fever and dyspnea associated with purulent sputum. Physical examination reveals dullness on percussion on the right lower chest and rales on auscultation (see reports). Chest radiography: Pneumonic infiltrate in the right upper lobe and a pleural effusion. Aspiration: Pending result. = pH < 7.2

0034. A 29-year-old woman in the second trimester of pregnancy presents to the Emergency Room due to progressive dyspnea for the past 24 hours. Examination reveals clear lungs and a swollen right lower limb (see lab results and report). Chest radiography: Normal. = Doppler ultrasonography of the legs

0035. A 50-year-old man is 6 days post-uneventful subtotal colectomy and ileocolic anastomosis when he develops sudden-onset shortness of breath and one episode of hemoptysis. Examination reveals mildly decreased breath sounds at the left lung base, normal S1 and S2, a soft and lax abdomen with normal bowel sounds, and no lower extremities edema or tenderness (see lab results and reports). Chest X-ray: Left basilar atelectasis. ECG: Sinus tachycardia and a new finding of a right bundle branch block. = CT pulmonary angiography

0036. A 30-year-old man presents with cough, fever, and right-sided pleuritic chest pain for 2 days. He is a non-smoker and works as a school teacher. He has no significant past medical history and does not take any medicine. Examination reveals bronchial breath sounds at the right lower chest (see report). Chest X-ray: Right lower lobe pneumonia and 25 mm pleural effusion on decubitus film. = Perform diagnostic thoracentesis

0037. A 44-year-old woman is seen in the clinic with difficult-to-control asthma despite being on high-dose inhaled steroids and frequent courses of systemic steroids. She also has a history of allergic rhinitis and nasal polyps. She claims to use aspirin and ibuprofen for migraine almost daily. She is a non-smoker and works in a school. Examination reveals nasal polyps and bilateral expiratory wheezing on chest auscultation (see report). Chest X-ray: Normal. = Discontinue aspirin and ibuprofen and start Montelukast

0038. A 63-year-old man is evaluated for hemoptysis and a 5-kg weight loss over the last 2 months. He has a history of 30 pack-years of smoking but stopped 10 days ago (see reports). Chest X-ray: 5-cm irregular mass in the right upper lobe. Fiberoptic bronchoscopy: Tumor in the right upper lobe bronchus. Biopsy: Squamous cell carcinoma. Whole body FDG-PET scan: Negative for metastasis. = Pulmonary function tests

0039. A 55-year-old man with a long history of smoking presents to the Emergency Room with exertional shortness of breath and a daily productive cough of 3-4 tablespoons of yellow sputum that has worsened over the last 3 days. No history of fever, chest pain, or hemoptysis. Chest examination reveals decreased breath sounds and scattered rhonchi. = Ipratropium bromide

0040. A 33-year-old woman with rheumatoid arthritis for 3 years is evaluated in the Emergency Department with a 3-day history of pain and swelling of the left knee and low-grade fever. There was no history of trauma. Her medications are prednisone, methotrexate, and etanercept. Joints examination reveals a swollen and tender left knee, and mild synovitis is present on the third proximal interphalangeal joint bilaterally. = Arthrocentesis of the left knee

0041. A 40-year-old woman presents with pain and swelling of the hands with early morning stiffness for 3 months. She has photosensitivity, hair loss, difficulty climbing stairs, and Raynaud’s phenomenon. Examination reveals active arthritis at the second and third proximal interphalangeal joints, malar rash, and healed ulcers at the tip of the second finger. Proximal muscle strength is 3/5 (see lab results). = Anti-ribonucleoprotein (RNP)

0042. A 28-year-old woman with active neuropsychiatric lupus based on clinical manifestations and her workups. = Corticosteroids and cyclophosphamide

0043. A 35-year-old man is evaluated during a follow-up visit. He is a known case of rheumatoid arthritis that is well controlled with prednisone 15 mg and hydroxychloroquine 400 mg daily. His physical examinations are unremarkable (see lab results). = Taper prednisone and start methotrexate

0044. A 50-year-old man is evaluated in the clinic for newly diagnosed hypertension that is not well controlled with lifestyle modifications. His systemic examinations are unremarkable (see lab results). = Lisinopril and amlodipine

0045. A 55-year-old man with acute coronary syndrome who recently underwent cardiac catheterization is evaluated because of acute kidney injury. = Eosinophiluria

0046. A 60-year-old man who has been on hemodialysis for the last 10 years is evaluated in the clinic. He is complaining of fatigue but has no other symptoms. His physical examination is unremarkable (see lab results). = Cardiovascular disease

0047. A 30-year-old woman with Sjogren’s syndrome on hydroxychloroquine is evaluated in the clinic because of fatigue. Her physical examinations are unremarkable (see lab results). = Type 1

0048. A 35-year-old woman presents to the Emergency Department with fever and shortness of breath for 2 days. She is a known rheumatoid arthritis patient on hydroxychloroquine 400 mg daily. Examination reveals crepitations at the right lower lung. Renal and liver function are normal. She was treated with cefuroxime with resultant significant improvement. However, her renal function is deteriorating (see lab results). = Acute interstitial nephritis

0049. An 18-year-old man is evaluated because of acute kidney injury 3 days after an upper respiratory tract infection. Examination reveals lower limb pitting edema up to the knee levels. His laboratory investigations were normal 3 days ago but are repeated today (see lab results). = IgA nephropathy

0050. A 28-year-old man who recently joined military service and underwent excessive military training presents to the Emergency Department with lightheadedness on standing and fatigue. Physical examination reveals postural hypotension, otherwise unremarkable. Urine osmolality is elevated > 500 mosmol/L (see lab results). = Pre-renal azotemia

0051. A 28-year-old man who recently joined military service and underwent excessive military training presents to the Emergency Department with lightheadedness on standing, muscle cramping, and fatigue. Physical examination reveals postural hypotension, otherwise unremarkable. A diagnosis of acute kidney injury due to hypovolemia is established. = Blood urea nitrogen/creatinine ratio is elevated > 20

0052. A 55-year-old man with stage 2 chronic kidney disease is evaluated because of anemia. He is complaining of fatigue. His physical examination reveals pale skin, otherwise unremarkable (see lab results). = Serum iron studies

0053. A 64-year-old man known to have liver cirrhosis secondary to chronic hepatitis C completed treatment for HCV and now has undetectable HCV RNA 12 weeks post-treatment. He is asymptomatic. Clinically, he has a few spider angiomata and mild splenomegaly (see lab results). = Liver ultrasound every 6 months

0054. A 34-year-old woman, a known case of SLE on hydroxychloroquine, came to the clinic for a routine checkup. She is asymptomatic with an unremarkable clinical examination. Urine analysis and her blood tests are done. She underwent renal biopsy, which revealed Class I (minimal change) lupus nephritis (see lab results). = Control of blood pressure

0055. A 26-year-old man is evaluated in the Emergency Department 1 hour after having a first- time generalized tonic-clonic seizure. He has never had a seizure previously or any episode of jerking, staring, confusion, or memory loss. He has had no recent illness and has no history of neurological problems. Birth and development were normal. There is no family history of seizures or epilepsy. He takes no medication and does not use illicit drugs. His vital signs are normal. Neurological findings are unremarkable. Results of laboratory studies show a normal complete blood count and metabolic panel. = Head CT scan

0056. A 44-year-old man is presented to the Emergency Room 8 hours after the sudden onset of a global, severe headache with associated neck stiffness. The headache is described as the strongest he has ever had. He is known to have hypertension but is noncompliant with his medications. Examination revealed a discomfortable and restless patient. Funduscopic examination is normal with the left pupil being 2 millimeters larger than the right and poorly reactive to light, and he has neck stiffness with passive movement (see report). = Lumbar puncture

0057. A 55-year-old man is evaluated 2 days after having an episode of left arm weakness without pain that lasted 5 minutes. He is now asymptomatic. He has type 2 diabetes mellitus and dyslipidemia. Medications are aspirin, insulin, and atorvastatin. Physical examination shows that no carotid bruits or cardiac murmurs are heard on cardiac auscultation, and all other physical examination findings are normal (see report). Electrocardiogram: Normal sinus rhythm with no ST-segment or T-wave changes. = Carotid duplex ultrasonography

0058. A 59-year-old man is evaluated in the hospital for progressive shortness of breath and hypoxia 20 hours after undergoing surgery for colonic adenocarcinoma with known liver metastases (see report). CT angiography: Shows a right lower lobe pulmonary embolism. = Enoxaparin

0059. A 30-year-old woman is evaluated for new-onset nonproductive cough and dyspnea on exertion. She is pregnant at 30 weeks gestation. Medical history is unremarkable. Her only medication is a prenatal vitamin. Cardiopulmonary examination is normal. She has a gravid uterus and 2+ edema of the lower extremities without calf tenderness. Doppler ultrasonography of both legs is negative for deep venous thrombosis (see lab results). = Ventilation-perfusion lung scan

0060. A 49-year-old woman undergoes perioperative evaluation. She has osteoarthritis of the right hip and is scheduled for elective hip arthroplasty. Medical history is otherwise notable for type 2 diabetes mellitus. Her menstrual period has been heavy for the last few months. Medications are ibuprofen and metformin. Vital signs are normal. She has painful and limited range of motion in the right hip (see lab results). = Iron studies

0061. A 29-year-old woman arrives at the hospital in labor at 38 weeks gestation of an otherwise uncomplicated second pregnancy. Her labor fails to progress after 20 hours; a cesarean section delivers a healthy female infant. A few minutes after the procedure, the patient begins to have heavy vaginal bleeding. Placental abruption is diagnosed and appropriately managed with fluid resuscitation and transfusion of 4 units of blood, yet she continues to have moderate bleeding (see lab results). = Cryoprecipitate

0062. A 70-year-old woman presents with fatigue and exertional dyspnea for several months. Medical history includes longstanding hypertension and chronic kidney disease, and she is not adherent to her medications. Examination reveals pale mucous membranes and nail beds (see lab results and report). Kidney ultrasonography: Showed small kidneys bilaterally with echographic features suggesting chronic kidney disease. = Erythropoietin deficiency

0063. A 32-year-old woman presents to the clinic with decreased exercise tolerance and ice cravings for the past several months. Medical history is notable for celiac disease diagnosed 7 years ago, and she is not compliant with a gluten-free diet. Her only medication is ferrous sulfate tablets 325 mg once daily, which she has been taking for 12 weeks after being diagnosed with iron deficiency anemia. Examination reveals a thin patient with normal vital signs, pale conjunctivae, and nail beds. Cardiac examination reveals a grade 2/6 systolic flow murmur (see lab results). = Intravenous iron preparation

0064. A 58-year-old woman presents to the follow-up clinic. She is known to have idiopathic deep venous thrombosis and is on warfarin, which was initiated 6 weeks ago. The examination is unremarkable (see lab result). = Re-measure INR in 2 days

0065. A 34-year-old woman at 38 weeks gestation is evaluated for a severe headache. Her only medication is a prenatal vitamin. Neurologic and cardiopulmonary examination is normal. She has a gravid uterus and 2+ edema of the lower extremities. No petechiae or ecchymoses are seen (see lab results and report). Peripheral smear: Occasional fragmented erythrocytes without platelet clumping. = Emergent delivery

0066. A 31-year-old woman known to have rheumatic mitral stenosis recently developed atrial fibrillation, for which she was placed on warfarin therapy. = 2.0-3.0

0067. A 25-year-old woman is seen for a routine prenatal evaluation; she is 12 weeks pregnant. This is her second pregnancy; the first pregnancy was uncomplicated. Medical history is notable for sickle cell disease requiring 1 to 2 hospitalizations per year for painful events. She has no history of stroke or acute chest syndrome. Her only medication is a folic acid supplement. Cardiac examination reveals a grade 2/6 systolic flow murmur (see lab results). = Close observation throughout pregnancy

0068. A 55-year-old woman with type 2 diabetes mellitus was recently diagnosed with hypertension. = Ramipril

0069. A 60-year-old man is found to have elevated blood pressure during a routine checkup. He has no symptoms, and physical examination is unremarkable. ECG, CBC, electrolytes, renal function tests, and urine analysis are normal. = Perform ambulatory blood pressure measurement

0070. A 75-year-old man with COPD presented with acute exacerbation due to super-added pneumonia. He was managed with IV fluids, antibiotics, nebulized salbutamol, and nasal oxygen at 4 L/min. A few hours later, he started to become drowsy (see lab results). = Reduce inspired oxygen concentration

0071. A 55-year-old man presented with a productive cough for 3 months. He had a similar attack of chronic cough for the previous 2 years. He smokes 1 pack/day for the last 15 years. Examination revealed an obese patient with scattered wheeze and crackles over the lungs. = Chronic bronchitis

0072. A 55-year-old man, a plumber, presented with a 1-year history of dry cough and progressive exertional breathlessness. Examination shows finger clubbing and bilateral basal crackles (see reports). Chest X-ray: Bilateral reticular shadowing at the lower zone of the lungs. = High-resolution CT scan of the chest

0073. A 65-year-old man known to have COPD admitted with 2 weeks of worsening productive cough and breathlessness. Examination shows that he is drowsy with bilateral wheeze over the chest (see lab results). = Nebulized salbutamol and ipratropium

0074. A 61-year-old obese man presented with daytime somnolence, poor concentration, nocturia, and progressive shortness of breath. Examination reveals an obese patient with bilateral lower limb edema and normal vesicular breath sounds on lung auscultation. = Sleep study

0075. A 62-year-old diabetic woman was admitted to the Intensive Care Unit with pneumonia and sepsis (see lab results and report). Chest X-ray: Right lobe consolidation and pleural effusion. = Diabetes mellitus

0076. A 64-year-old diabetic woman was admitted to the Intensive Care Unit with pneumonia and sepsis. She has no chronic lung disease and is not a smoker (see lab results and report). Chest X-ray: Right lobe consolidation and pleural effusion. = Moxifloxacin

0077. A 65-year-old woman presented with a 4-month history of progressive shortness of breath, dry cough, and fatigue. She was treated for pneumonia with 2 courses of antibiotics but showed no improvement in her symptoms. She has no significant medical problems (see reports). Chest X-ray (after antibiotics): A persistent dense area of consolidation at the right lower lobe. Bronchioalveolar lavage: Atypical cells. = Bronchogenic cancer

0078. A 45-year-old woman, a smoker for 18 years, presented with exertional shortness of breath and a chronic cough for 5 months. She is also known to have long-standing rheumatoid arthritis. Chest examination revealed increased AP diameter with hyperresonance all over the chest and scattered crackles (see report). Pulmonary function test: Increase in total lung capacity and residual volume. FEV1 60% with no change post-bronchodilator. = Emphysema

0079. A 17-year-old student presented with recurrent attacks of mild wheeze and shortness of breath despite using inhaled salbutamol regularly. = Inhaled corticosteroid

0080. A 70-year-old man presented to the Emergency Department with a 2-hour history of confusion and irritability. He was well until 5 days ago, when he injured his right leg and has been bed-bound since the accident. He is hypertensive and well-controlled on medication. He has no fever (see reports). Chest X-ray: Normal. ECG: Sinus tachycardia. = Pulmonary embolism

0081. A 65-year-old man, a smoker who was recently diagnosed with COPD, complains of shortness of breath on moderate exertion. He has no other medical problems, and chest examination was unremarkable. = Smoking cessation

0082. A young man with HIV was admitted to the Intensive Care Unit with progressive shortness of breath, cough, and fever. Examination showed he was dyspneic and cyanosed (see report). Chest X-ray: Signs of ARDS. = Pneumocystis jiroveci

0083. A 17-year-old man developed febrile neutropenia and shock post-chemotherapy for lymphoma. = Meropenem

0084. A 45-year-old man was admitted to the Intensive Care Unit with fever. He required a vasopressor to maintain a mean arterial pressure (MAP) of more than 65 mm Hg. He is receiving adequate IV fluid resuscitation (see lab result). = Septic shock

0085. A 35-year-old woman presented to the clinic with a 3-month history of fatigue, lethargy, and weight gain. Physical examination is unremarkable (see lab results). = Thyroid-stimulating hormone (TSH)

0086. A 32-year-old woman is evaluated because of a 3-month history of weight loss, heat intolerance, tremor, and irritability. Physical examination reveals a tremor and a non-tender goiter. She has negative thyroid-stimulating immunoglobulins (see lab results). = Toxic nodular goiter

0087. A 25-year-old man with type 1 diabetes mellitus on insulin therapy was found in the clinic waiting area drowsy and excessively sweating. A quick measurement of blood glucose revealed a low level. = Give fruit juice

0088. A 32-year-old housemaid was brought to the Emergency Room with headache, confusion, and fever for 2 weeks. She just came from India 1 month ago. Examination reveals a confused patient with neck rigidity. Fundus examination shows papilledema (see lab results and report). Brain CT scan: No masses or hemorrhage. = Start isoniazid (INH), rifampin, pyrazinamide, and ethambutol

0089. A 27-year-old woman presents to the clinic with a 1-week history of fever, sore throat, difficulty swallowing, and painful swelling in her neck. She had an upper respiratory tract infection 3 weeks ago. She has no past medical history. Examination reveals a tender goiter. Her oropharynx is clear (see lab results). = Subacute thyroiditis

0090. A 44-year-old Saudi man is evaluated because of a 3-month history of fever and back pain that radiates to his legs. His examination reveals bony tenderness over the entire back. Blood culture shows gram-negative coccobacilli. = Brucellosis

0091. A 25-year-old man was recently diagnosed with inflammatory bowel disease. = Non-caseating granuloma in biopsy

0092. A 35-year-old woman presents to the clinic with a 5-month history of fatigue. She takes no medication. Her examination is unremarkable (see lab results). = Thyroxine

0093. A 38-year-old man with a 10-year history of gastroesophageal reflux disease on pantoprazole is evaluated in the clinic because of a 4-month history of intermittent dysphagia for solids. = Endoscopy

0094. A 60-year-old man is evaluated in the clinic because of a 6-month history of exertional shortness of breath. Clinical examination reveals a positive Corrigan’s pulse, early diastolic murmur at the left upper sternal border, and bilateral fine basal crepitations (see report). Echocardiogram: Severe aortic regurgitation and ejection fraction of 40%. = Surgical valve replacement (AVR)

0095. A 45-year-old man with diabetes mellitus for 4 years on metformin is evaluated in the clinic because of an abnormal liver function test. He is clinically asymptomatic. His examination is unremarkable (see lab results). = Non-alcoholic fatty liver disease

0096. A 55-year-old man with liver cirrhosis on regular follow-up presents to the Emergency Room with a 2-day history of decreased level of consciousness and increased abdominal girth. Examination reveals an ill and cachectic patient with tense ascites and lower limb pitting edema bilaterally. = Start diuretic and spironolactone

0097. A 50-year-old man with cirrhosis presented to the Emergency Room with increasing ascites and decreased level of consciousness over one week. Examination revealed a confused patient with tense ascites (see lab results). = Stage B

0098. A 55-year-old man with diabetes mellitus for 10 years was admitted to the Intensive Care Unit with severe pneumonia that required intubation and ventilation. He was treated with intravenous antibiotics, and his vital signs, including his blood pressure, were maintained within the normal range. However, last night, he developed hypotension that required two inotrope agents (see lab results). = Ischemic hepatitis

0099. A 23-year-old man presents to the clinic with a 7-month history of recurrent episodes of abdominal pain and diarrhea that are sometimes associated with streaks of blood and occasional audible peristalsis. He had fever and loss of appetite for the last 7 days. There is no history of allergy or chronic use of any medications. Examination reveals a thin, ill-looking patient with a tender but soft abdomen (see lab results). = Inflammatory bowel disease

0100. A 50-year-old man known to have chronic viral hepatitis presented with ascites and was found to have a high serum ascites albumin gradient (SAAG) of more than 1.1. = Liver cirrhosis

0101. A 35-year-old Indian man presents to the Emergency Department with lethargy, weight loss, and headache for 3 months. He has a history of contact with a tuberculosis patient several years ago. His neurological and ophthalmologic examination are unremarkable. He has a positive polymerase chain reaction for Mycobacterium tuberculosis (see lab results). = Isoniazid, rifampin, pyrazinamide, ethambutol and dexamethasone

0102. A 29-year-old nurse is evaluated in the clinic for employment contract renewal. She is asymptomatic, and her clinical examination is unremarkable. Her laboratory tests are within normal range. Her skin purified protein derivative (PPD) test after 48 hours is 12 mm. = Isoniazid 300 mg daily for 6 months

0103. A 48-year-old woman is evaluated for persistent fever and flank pain. She was admitted several days ago for treatment of pyelonephritis. Her fever is persistent after 5 days of starting an appropriate antibiotic. Examination reveals tenderness over the left loin area, otherwise unremarkable (see report). Urine culture: Positive for Escherichia coli susceptible to the antibiotic that was already started. = Kidney ultrasound

0104. A 33-year-old pregnant woman in her third trimester is evaluated in the clinic for her routine checkup visit. She is asymptomatic and denies a history of fever, dysuria, or urgency. Her examination is unremarkable (see lab results and report). Urine culture: Positive for Escherichia coli susceptible to different broad-spectrum antibiotics. = Amoxicillin

0105. A 35-year-old man presents to the clinic with a 4-month history of fever, night sweats, fatigue, arthralgia, and lower back pain. He had a history of unpasteurized milk ingestion. His examination reveals right knee arthritis and limited spinal movements. His cardiopulmonary examination is unremarkable (see lab results and reports). Right knee joint aspiration: WBC 15,000 (0-200). Blood culture: Negative. = Serology for brucellosis

0106. A 33-year-old woman was admitted to the hospital after a road traffic accident that resulted in multiple fractures and had undergone multiple orthopedic surgical procedures. She has a positive urinary culture for Candida albicans. She denies any history of fever or urinary symptoms. She had an indwelling urinary catheter. Her examination is unremarkable. = No antifungal therapy

0107. A 22-year-old man is evaluated for a 2-day history of dysuria and urethral discharge. He had recent sexual activity with a new female partner. He is afebrile, and his examination is unremarkable (see report). = Azithromycin

0108. A young woman with acute uncomplicated pyelonephritis is evaluated in the Emergency Department. = Treat as outpatient with ciprofloxacin

0109. A 45-year-old man presents to the Emergency Department with a 3-day history of fever and a productive cough of yellowish sputum. Medical history is significant for type 2 diabetes mellitus. He is a smoker. His chest examination reveals decreased breath sounds throughout and crackles at the right lung base. Other systemic examination is unremarkable (see report). Chest radiograph: Right lower lobe infiltrate. = Outpatient treatment with cefuroxime and azithromycin

0110. A patient with highly suspicious pulmonary tuberculosis is evaluated in the Emergency Department. Standard universal precautions are taken. = Standard and airborne precautions

0111. A young man who is sexually active is evaluated in the clinic for clinical features that suggest gonorrhea. = Urethral swabs

0112. A 60-year-old man who has a history of mitral valve replacement with a mechanical prosthesis is admitted with infective endocarditis (see report). Blood culture: Positive for methicillin-resistant Staphylococcus aureus (MRSA). = Vancomycin, rifampin, and gentamicin

0113. A 60-year-old man with diabetes and hypertension presented to the Emergency Department with 3-hour continuous retrosternal heaviness associated with profuse sweating. Physical examination reveals tachycardia and an S4 gallop on heart auscultation. The patient is commenced on aspirin, clopidogrel, metoprolol, and nitroglycerin infusion (see reports). Electrocardiogram: Sinus tachycardia with left bundle branch block. Previous ECG was normal. Cardiac enzymes: Pending. = Administer thrombolytic therapy

0114. A 44-year-old man complains of dyspnea on exertion. Heart auscultation reveals an early diastolic murmur at the base of the heart. The intensity and duration of the murmur increase during inspiration. = Pulmonary regurgitation

0115. A 55-year-old woman with interstitial lung disease presented with exertional dyspnea and bilateral lower limb edema. Physical examination revealed an elevated JVP with a prominent v- wave, pulsating hepatomegaly, a left parasternal heave, and a loud pulmonary component of the second heart sound (P2). = Tricuspid regurgitation

0116. A 65-year-old man came to the Emergency Room after his wife said he went to bed without complaints but woke up 2 hours later unable to walk or speak. He is known to have type 2 diabetes mellitus, hypertension, dyslipidemia, and osteoarthritis, and is on insulin, metformin, candesartan, hydrochlorothiazide, aspirin, and atorvastatin. Examination reveals he is conscious but disoriented. Right side of his body has power of 2/5 (see image). = rtPA (recombinant tissue plasminogen activator)

0117. A 73-year-old woman is brought to the emergency room by family members who noticed a change in her level of consciousness for 1 day. She is known to have type 2 diabetes mellitus, hypertension, ischemic heart disease, and liver cirrhosis. Examination reveals she is drowsy, with raised JVP, positive shifting dullness, and +2 lower limb edema (see lab results). = Furosemide

0118. A 63-year-old man presents to the clinic with fatigue and tiredness. No fever, shortness of breath, chest pain, abdominal pain, or vomiting. He is known to have type 2 diabetes mellitus, hypertension, dyslipidemia, and chronic kidney disease stage IV. Examination reveals a well- looking patient, not in distress, with normal JVP and no lower limb edema (see lab results). = Start erythropoietin

0119. A 70-year-old gentleman known to have liver cirrhosis with esophageal varices underwent endoscopic variceal ligation 1 month ago. = B blocker

0120. A 33-year-old woman, who is known to have bronchial asthma and chronic sinusitis, is complaining of worsening shortness of breath and a cough that disturbs her sleep. She denied any fever, headache, or chest pain. Her medications include salbutamol MDI prn and paracetamol. Chest examination reveals bilateral expiratory wheezes. = Budesonide MDI

0121. A 65-year-old man, a heavy smoker, known to have hypertension and COPD on Ventolin, Anoro Ellipta (Umeclidinium bromide/vilanterol), and lisinopril, presents with worsening shortness of breath for 4 months. There has been no change in his sputum amount or purulence, and he has had no fever, PND, or orthopnea. He was not admitted to the hospital for more than a year. Examination reveals decreased breath sounds without added sounds (see lab results and report). Chest CT 6 months ago: Diffuse emphysematous changes. = Home oxygen

0122. A 55-year-old man known to have psychiatric disease and hypertension was admitted to the hospital due to poor nutrition at home, as he was refusing food. During hospitalization, he became agitated, so they increased the dose of Haloperidol. Suddenly, he became confused and began sweating. He was shifted to the ICU, started on IV fluids, and intubated (see lab result). = Bromocriptine

0123. A 76-year-old man, known to have type 2 diabetes mellitus, hypertension, and dyslipidemia, presented to the clinic with exertional shortness of breath for 1 year. He has to slow down his walk and stop after 10 meters. He denied any history of syncope, chest pain, or palpitation. Precordium examination revealed a forceful apex beat and a crescendo- decrescendo ejection systolic murmur radiating to the carotid. = Aortic stenosis

0124. A 62-year-old woman known to have type 2 diabetes mellitus, hypertension, dyslipidemia, and ischemic stroke 1 month ago, presented to the Emergency Room complaining of central stabbing continuous chest pain for 3 hours. She denied any dyspnea, palpitation, or change in consciousness. The patient is taking insulin, lisinopril, metoprolol, lipitor, and aspirin. Examination revealed she is in pain. She was started on oxygen, morphine, and sublingual nitroglycerin (see image). = Urgent coronary angiography

0125. A 58-year-old man known to have type 2 diabetes mellitus, hypertension, and ischemic heart disease. His medications are metformin, sitagliptin, aspirin, lipitor, and lisinopril. He works as a car mechanic. For the last 4 months, he has started to notice exertional shortness of breath that interferes with his job but does not limit him from doing it, provided that at rest, he is fine without any shortness of breath. = Class II

0126. A 35-year-old woman who had an uncomplicated vaginal delivery 2 weeks ago presented to the Emergency Room complaining of chest pain for 1 day, associated with exertional shortness of breath, no cough, no fever, no orthopnea, and no PND. Examination revealed an ill-looking woman (see reports). = Pulmonary embolism

0127. A 38-year-old woman who is not known to have any medical illness is referred to the clinic because of a chest x-ray that showed prominent hilar structures bilaterally. She is having on- and-off cough but denies any history of shortness of breath, sputum production, chest pain, skin lesions, weight loss, fever, or contact with sick people. She is not a smoker. Examination reveals clear chest bilaterally (see lab results and reports). CT chest: Confirmed bilateral hilar lymphadenopathy, otherwise lung parenchyma was clear. CT-guided biopsy: Showed noncaseating granuloma. = Observe

0128. A 68-year-old woman known to have type 2 diabetes mellitus, hypertension, and end- stage renal disease on hemodialysis complains of shortness of breath and increasing bilateral lower limb swelling. She denies any fever, chest pain, cough, abdominal pain, or vomiting. Examination reveals an ill-looking patient with high JVP and +3 lower limb edema. ECG was ordered (see lab result). = Peaked T wave

0129. A 78-year-old man known to have type 2 diabetes mellitus, hypertension, and chronic kidney disease is complaining of fatigue and nausea. He denies any change in consciousness, seizures, abdominal pain, vomiting, chest pain, or shortness of breath. He is on insulin, lisinopril, amlodipine, erythropoietin, and vitamin D. Examination reveals that he is drowsy but not in distress (see lab results). = Calcium gluconate

0130. A 33-year-old woman known to have systemic sclerosis with normal kidney function, diagnosed 2 years ago, is on pantoprazole. She complains of drowsiness and visual changes, denies fever, cough, shortness of breath, chest pain, seizures, abdominal pain, or vomiting. Examination reveals an unwell patient with raised JVP, clear chest, and +3 lower limb edema (see lab result). = Lisinopril

0131. A 45-year-old woman known to have end-stage renal disease secondary to type 1 diabetes mellitus came to the clinic for a routine follow-up. She had no complaints but was found to have abnormal blood results (see lab results). = Calcitriol

0132. A 38-year-old woman known to have type 2 diabetes mellitus just returned from Makkah. She complains of fever, lethargy, and headache. She has no cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or skin rash. Examination reveals a drowsy patient with positive neck stiffness (see report). Lumbar puncture: Low glucose, markedly increased protein, WBC 9000 with predominantly neutrophils. = Ceftriaxone and vancomycin

0133. A 28-year-old woman, not known to have any medical illness, complains of increased sleepiness, fatigue, and constipation for the last few months. She is on a very healthy diet, is not a smoker, and does not drink alcohol. Examination reveals an overweight patient, not in distress, with no lymphadenopathy or masses (see lab results). = Hashimoto’s thyroiditis

0134. A 65-year-old man was brought to the Emergency Room by his wife after she noticed he was confused and behaving in a strange way. He had no fever, cough, shortness of breath, chest pain, headache, abdominal pain, vomiting, or loss of consciousness. He is known to have type 2 diabetes mellitus, hypertension, dyslipidemia, and osteoarthritis, and is on insulin, metformin, candesartan, hydrochlorothiazide, aspirin, and atorvastatin. Examination reveals that he is conscious but disoriented. Left leg power is 2/5, while the other limbs are 5/5. There is decreased sensation in the left leg. Other neurological exams are normal. = Right ACA stroke

0135. A 22-year-old man presented to the Emergency Room with left leg swelling and pain that started 2 days ago and is getting worse. It involves the whole left leg. He also complains of chest tightness and shortness of breath. Examination reveals left lower limb pitting edema extending to the thigh (see report). ECG: Sinus tachycardia. = Unfractionated heparin

0136. A 45-year-old man presented to the Emergency Room with palpitations. Initially, he was conscious and oriented. His vital signs were as shown. After some time, he became less responsive, and his blood pressure dropped to 80/45 mmHg (see report). ECG: Supraventricular tachycardia (SVT). = Cardioversion

0137. A 16-year-old boy came to the Emergency Department complaining of exertional dyspnea and easy fatiguability for the past few weeks. His parents admitted that he used to be a sick child requiring multiple hospital admissions and frequent blood transfusions. His parents are related. He was found to be pale, jaundiced, and have hepatosplenomegaly, with a scar from laparoscopic cholecystectomy (see lab results). = Hemoglobin electrophoresis

0138. A 70-year-old man presented to the Emergency Department complaining of increasing shortness of breath and a productive cough for the past 5 months. He has been a smoker for over 50 years. Over the course of 5 months, he complained of malaise, night sweats, fever, and has lost 10 kg over the last 3 months. = Lung carcinoma

0139. A 60-year-old man was admitted to the hospital because of community-acquired pneumonia. On hospital day 3, he developed increasing shortness of breath and became severely hypoxic, necessitating mechanical ventilation with a PaO2/FiO2 of 180 (see report). Chest X-ray: Bilateral lung infiltrates. = Acute respiratory distress syndrome (ARDS)

0140. A 25-year-old college student came for a routine checkup. He does not have any active complaints. Examination reveals a diastolic murmur heard at the base of the heart, which increased when the patient leaned forward in full expiration. = Aortic regurgitation

0141. A 39-year-old woman presented to the family medicine clinic for counseling as she is planning to get pregnant. She gave a history of hypertension and is controlled on an angiotensin-converting enzyme inhibitor (ACEI). Her physician asked her to change the medication as it is contraindicated during pregnancy. = Increases the rate of fetal malformation

0142. A 23-year-old man known to have Hodgkin’s lymphoma, undergoing chemotherapy, developed tumor lysis syndrome. = Hyperkalemia and hypocalcemia

0143. A 50-year-old man known to be an alcoholic presented with progressive abdominal distention and yellow discoloration of the sclera. The patient gave a history of vague abdominal pain mainly at the epigastrium. Fluid thrill was found upon examination, suggestive of ascites. Diagnostic paracentesis was done (see lab results). = Portal hypertension

0144. A 45-year-old man was recently diagnosed with hypertension. He has a family history of ischemic heart disease. An angiotensin receptor II blocker was prescribed to control his blood pressure and reduce the risk of ischemic heart disease. = Irbesartan

0145. A 42-year-old man presented to the hospital complaining of shortness of breath, fever, and fatigue for the past few days. Examination showed he has high JVP, pulsus paradoxus, and distant heart sounds. Lung auscultation was clear (see reports). ECG: Low voltage. Chest X-ray: An increase in cardiac silhouette. = Pericardium

0146. A 22-year-old woman was brought to the Emergency Room after ingesting 50 tablets of extra strength acetaminophen (500 mg each tablet) 3 hours ago. The patient is conscious and oriented (see lab results). = N-acetylcysteine and charcoal

0147. A 43-year-old man presented to the hospital with right leg swelling and pain. He has a history of pulmonary embolism 5 years ago and is currently not taking any medications. Doppler ultrasound confirmed the diagnosis of proximal Deep Vein Thrombosis (DVT). = Long-term anticoagulation

0148. A 36-year-old man, previously healthy, presented to primary healthcare complaining of cough, fatigue, sore throat, and body aches. The cough is productive with whitish sputum; on a few occasions, there were some blood streaks. Chest examination was within normal limits (see report). Chest X-ray: Normal, without evidence of consolidation. = Bronchitis

0150. A 42-year-old homeless man was recently released from prison. He presented to the Emergency Room with a fever, productive cough, weight loss, and night sweats over the past 3 months (see report). Chest X-ray: Left lung apical infiltration. Sputum sample was collected and sent to the lab. = Ziehl-Neelsen stain

0151. A 35-year-old man comes to the Emergency Room after falling while running a marathon. He has dark urine that is dip-stick positive for large blood, but no RBCs on microscopic analysis. = Rhabdomyolysis

0152. A 35-year-old man comes to the Emergency Room after falling while running a marathon. He has dark urine that is dip-stick positive for large blood, but no RBCs on microscopic analysis. = Hydration

0153. A 50-year-old woman presents with nausea, vomiting, and muscle aches. She is 6 days post-operative and is unable to pass stool, and has abdominal distension (see lab results). = ECG

0154. A patient with acute leukemia recently underwent allogenic bone marrow transplantation. After 2 weeks, she was neutropenic and developed a fever and cough. She was diagnosed with invasive aspergillosis based on radiological and microbiological assessment. = Voriconazole

0155. A 32-year-old woman presents with pain in her hands and knees on and off for 2 months. She had 3 abortions in the first trimester. Examination reveals a rash over the nose bridge, swelling and tenderness of the small joints of the hands, and a warm, tender, erythematous swelling of the right calf that is 2 cm larger in circumference than the left (see lab results). = Lifelong warfarin therapy

0156. A 46-year-old woman presented to the Emergency Room with back pain for 3 weeks associated with fever. She was sent home with NSAIDs and bed rest recommendations but returned after 2 days with the inability to move her legs. Examination revealed a febrile patient with tenderness in the mid-back and upper motor neuron signs in the lower limbs associated with weakness 3/5 (see lab results and report). MRI spine: Diffuse discitis in T6 vertebrae. = Brucella titers

0157. An 85-year-old man admitted to the Intensive Care Unit following a massive stroke suddenly developed new weakness. Physical examination confirmed papilledema (see report). Emergency CT brain: Hemorrhagic transformation. = Craniotomy and decompression

0158. A 59-year-old woman admitted with an infected bedsore and had debridement 2 days ago. She suddenly developed mental confusion and poor response to commands. = Septic shock

0159. A 22-year-old prisoner presented with fever, productive cough, and weight loss for 3 weeks. He was admitted to isolation as a case of open tuberculosis (TB), and the next day, he was discovered to be HIV positive. = Start anti-TB therapy alone to prevent immune reconstitution inflammatory syndrome

0160. A 70-year-old man complains that he cannot remember things, sometimes forgetting names of friends, famous community figures, and telephone numbers. His wife fears he has Alzheimer’s disease. Physical examination is unremarkable apart from tender knee joints (see lab results). = Benign forgetfulness

0161. A 39-year-old man diagnosed with pancreatic cancer develops a swollen left lower limb during hospitalization. Examination reveals a tender, erythematous swelling affecting the left leg. = Deep vein thrombosis

0162. A 16-year-old boy presents with a 4-day history of a rash over his legs associated with abdominal pain and aches in both knees. He had one bout of bloody loose bowel motions. Physical examination reveals an erythematous palpable rash extending up to his buttocks (see reports). = Henoch-Schönlein purpura

0163. A 20-year-old woman, recently married, presents with burning micturition for one week. Physical examination reveals suprapubic tenderness (see lab results). = Oral nitrofurantoin

0164. A 65-year-old woman with long-standing chronic renal failure presents with aches and pains for 1 month. Physical examination is unremarkable apart from general pallor (see lab results). = Oral calcitriol

0165. A 38-year-old woman, mother of three, presents with fatigue and weight loss for the last few months. She was unable to breastfeed her last child and her menses did not return after giving birth. She has cold intolerance and loss of appetite. Examination reveals a croaky voice with delayed relaxation phase of her ankle jerks (see lab results). = Request Thyroid Stimulating Hormone (TSH) level

0166. A 22-year-old woman presents with recurrent seizures and cognitive dysfunction. She is subsequently diagnosed with glioblastoma multiforme (see lab results). = Syndrome of inappropriate ADH secretion

0167. A 60-year-old man known to have systemic hypertension, gout, and dyslipidemia presented to the Emergency Room 5 days ago with signs of heart failure and was diagnosed with congestive heart failure and new-onset diabetes mellitus. He was stabilized and discharged on Lasix, aspirin, Plavix, and metformin. Yesterday, he came to the ER with severe pain and redness in the first metatarsophalangeal joint. Examination confirms tenderness and swelling of that joint. = Lasix

0168. A 26-year-old woman complains of marked fear whenever dealing with unfamiliar people, as she is afraid of embarrassment. She was referred to a local psychologist for assessment and management. = Social phobia

0169. A 69-year-old man is diagnosed recently with lymphoma and started on chemotherapy. On day 7 post 4th cycle, he presented to the Emergency Room with fever. Examination precludes any underlying infection (see lab results). = Empiric IV antibiotics in a hospital setting

0170. A 55-year-old heavy smoker, smoking 4 packs a day, complains of occasional chest pain on exertion, which is relieved by rest. He presents to the clinic seeking help to stop smoking. Physical examination reveals an anxious patient with nicotine stains on the fingers and peripheral cyanosis. His jugular venous pulse is raised 8 cm. The rest of the exam is unremarkable. = Nicotine replacement therapy

0171. A 20-year-old woman is referred to Neurology Clinic because of an unsteady gait and transient loss of vision during a sports game at university. She has no history of fever, sweating, or recent trauma, and no past medical or drug history (see report). MRI Brain: Multiple demyelinating hyperintense lesions are seen distributed in the periventricular white matter and callososeptal regions bilaterally. = Multiple sclerosis

0172. A 48-year-old woman with rheumatoid arthritis presents to the clinic with a 2-week history of joint pain and increased morning stiffness lasting almost 45 minutes. Her current medications include prednisolone 5 mg daily and methotrexate 15 mg weekly. Her examination reveals multiple swollen and tender joints (see lab results). = Biologic agent

0173. A 56-year-old man with chronic renal failure for 5 years presents to the clinic with fatigue for 3 months. His physical examination is unremarkable (see lab results). = Subcutaneous erythropoietin

0174. A 58-year-old woman with liver cirrhosis presents to the emergency with hematemesis (see report). = Octreotide

0175. A 60-year-old man with liver cirrhosis presents to the Emergency Room with increasing ascites. He has no history of fever or decreased level of consciousness. His medications include spironolactone 50 mg/day and furosemide 40 mg/day. His physical examination confirms the presence of large ascites (see lab results). = Therapeutic paracentesis

0176. A 21-year-old man with a recurrent history of wheezing and exertional shortness of breath when participating in exercises presents to the Emergency Room with increasing shortness of breath after an aerobic class. Examination reveals that he is having obvious difficulty in breathing with diffuse bilateral wheezes. = Inhaled salbutamol

0177. A 28-year-old man presents to the Emergency Room with shortness of breath on exertion that started after exercise. He has a history of intermittent wheezing in response to exercise. His chest examination reveals diffuse wheezes. = Inhaled salbutamol

0178. A 26-year-old man with type I diabetes mellitus on insulin presents to the clinic for regular follow-up. He is asymptomatic (see lab results). = Angiotensin-converting enzyme inhibitor

0179. A 38-year-old woman known to have systemic lupus erythematosus (SLE) presents for regular follow-up. She is feeling unwell. Examination reveals multiple joint swelling and oral ulcer. Her 24-hour urine collection showed proteinuria of 1.5 g/24h (see lab results). = Kidney biopsy

0180. A 35-year-old woman was referred to the clinic because she was found to have proteinuria. She is complaining of fatigue and lower limb swelling. Her examination reveals lower limb pitting edema up to the knees bilaterally. Her systemic examination is unremarkable (see lab results). = Kidney biopsy

0181. A 36-year-old woman who is hypertensive on hydrochlorothiazide and losartan presents to the clinic because of the absence of her menstrual cycle for 2 months. She is asymptomatic. Her physical examination is unremarkable. A pregnancy test was done and was positive (see lab results). = Discontinue losartan and start methyldopa

0182. A 60-year-old man presents to the Emergency Room with symptomatic hyponatremia. = Central pontine myelinolysis

0183. A 29-year-old man presents to the Emergency Room with a 2-day history of fever and painful skin eruption over the left side of his chest. His physical examination reveals a skin eruption consisting of maculopapular lesions and vesicles with some skin crusting over the left side of his chest. His systemic examinations are unremarkable. = No further investigation is required

0184. A 20-year-old woman is brought to the Emergency Room with a 2-day history of headache, fever, photosensitivity, lethargy, and skin eruption. Her examination reveals a drowsy woman with neck rigidity but no focal neurological findings. She has a purpuric skin rash over her extremities (see lab results). = Lumbar puncture

0185. A 35-year-old woman is evaluated in the clinic for thyroid enlargement. She is asymptomatic and has no significant past medical history. Her examination reveals a firm, mobile, non-tender nodule at the lower pole of the right lobe of the thyroid gland. The left lobe is normal to palpation. = Thyroid stimulating hormone (TSH)

0186. A 55-year-old man with acute myeloid leukemia on chemotherapy presents to the Emergency Room with a 1-day history of fever. His physical examination is unremarkable. His chest radiograph and urinalysis are normal. Blood and urinary cultures are taken (see lab results). = IV antibiotics

0187. A 50-year-old man presents to the Emergency Room with fever, progressive shortness of breath, and productive cough for 3 days. Examination is unremarkable except for coarse crackles at the right lower lung (see lab results and reports). Blood culture: Gram-positive cocci. Intravenous antibiotics are started. = Administer 1000 mL normal saline fluid bolus

0188. A 54-year-old man presents to the Emergency Room with an acute exacerbation of COPD. Examination reveals the use of accessory muscles of breathing, diminished gag reflex, decreased breath sounds with wheezing heard throughout both lung fields. Oxygen, glucocorticoids, antibiotics, and nebulizers are started (see lab results). = Intubate and start mechanical ventilation

0189. A 35-year-old man, who was medically free, was admitted to the Intensive Care Unit with massive pulmonary embolism. = Thrombolysis

0190. A 32-year-old woman presents to the clinic with a 3-month history of lower back pain associated with morning stiffness lasting almost 1 hour, as well as joint pain affecting both knees and ankles bilaterally. She denied any history of skin rash or mucosal ulcerations. No history of fever. Clinical examination reveals limited lumbar spine movements and active arthritis at both knees bilaterally. She also has tenderness over the Achilles tendon (see lab results). = Ankylosing spondylitis

0191. A 38-year-old woman presents to the Emergency Department with increased shortness of breath on exertion, palpitations, and fatigue for one week. Physical examination reveals pale conjunctiva and splenomegaly. Peripheral blood smear shows spherocytosis (see lab results). = Corticosteroid therapy

0192. A 30-year-old woman presents to the clinic with a 3-month history of palpitations and fatigue. Physical examination is unremarkable (see lab results). = Oral iron supplementation

0193. A 28-year-old man presents to the Emergency Department with a 2-week history of bloody diarrhea, lower abdominal cramps, and tenesmus. Physical examination reveals abdominal distension with mild tenderness (see lab results). = Colonoscopy

0194. A 50-year-old man with ischemic heart disease and diabetes presented to the emergency with severe pneumonia and was admitted to the intensive care unit (ICU). He was treated with a course of antibiotics. Three days after admission to ICU, he develops hypotension treated with hydration and inotropes. His liver function at the day of admission was normal, but the repeated one is abnormal (see lab results and report). Abdominal ultrasound: Unremarkable. = Ischemic hepatitis

0195. A 42-year-old man presents to the Emergency Room with productive cough, fever, and dyspnea for 3 days. Chest examination reveals evidence of consolidation at the right lower lung field. Baseline laboratory studies, two blood cultures, and sputum samples for cultures and gram stain are obtained. = Ceftriaxone and azithromycin

0196. A 60-year-old man with hypertension presents to the Emergency Room with sudden onset of retrosternal chest pain, dyspnea, and palpitations for 2 hours. His past medical history is significant for a non-hemorrhagic stroke 2 months ago (see lab results and report). ECG: ST-segment elevation in leads II, III, and aVF. = Percutaneous coronary intervention (PCI)

0197. A 55-year-old man presents to the clinic with progressive shortness of breath on exertion for 8 months. He has no history of chest pain or other systemic manifestations. Physical examination reveals an early diastolic murmur at the left upper sternal border that is augmented when sitting forward (see reports). Chest radiography: Cardiomegaly. ECG: Left ventricular hypertrophy. = Aortic regurgitation

0198. A 35-year-old woman presents to the Emergency Room with sudden onset of shortness of breath associated with pleuritic chest pain. Her past medical history is unremarkable. She is using oral contraceptives regularly. Physical examination is unremarkable. Imaging and laboratory tests are requested. = Chest CT angiography

0199. A 30-year-old man presents to the clinic with lower limb edema and fatigue for 1 month. Examination reveals pitting edema over both legs up to the knees. His systemic examinations are unremarkable (see lab results). = Acute glomerulonephritis (GN)

0200. A 30-year-old woman with stable systemic lupus erythematosus presents to the clinic with active polyarthritis for 1 week. = Prednisolone and methotrexate

0201. A 28-year-old man presents to the clinic with a 6-month history of lower back pain associated with morning stiffness for almost 1 hour, as well as joint pain affecting both knees and ankles bilaterally. He denied any history of skin rash or mucosal ulcerations. Clinical examination reveals limited lumbar spine movements, a positive modified Schober test, and active arthritis in both knees bilaterally. He also has tenderness over the Achilles tendon. = MRI of sacroiliac joint

0202. A 55-year-old man presents to the clinic with a 3-month history of fatigue and lethargy. Examination reveals pallor but no organomegaly. = Fecal occult blood (FOB)

0203. A 55-year-old male smoker presents to the Emergency Room with a sudden onset of retrosternal chest pain radiating to the neck. His systemic examination is unremarkable. ECG: ST-segment depression in II, III, and aVF. = Patient’s age

0204. A 32-year-old woman presents to the clinic with a 6-month history of mild fatigue. She does not have other symptoms. She is planning for pregnancy. Her physical examination is unremarkable. Her recent thyroid function is shown below. = Start Thyroxin during pregnancy

0205. A 38-year-old woman with a 2-year history of depression presents to the clinic for follow- up. Her husband raised a concern about suicide as she is looking more depressed and isolated recently. She denied any history of alcohol or psychoactive substance use. During her clinical exam, there was no eye contact and her systemic exams were unremarkable. = Social isolation

0206. A 32-year-old man with HIV presents to the clinic for follow-up. He is generally doing well. However, Mantoux tuberculin test (PPD) after 48 hours is 6 mm. His chest radiography (CXR) is unremarkable. = Isoniazid and pyridoxine for 9 months

0207. A 27-year-old woman presented at full term at labor, she was having uncontrolled diabetes during this pregnancy. = Respiratory distress syndrome

0208. A primipara presents 1 week after delivery. She is tearful, has spells of crying, and lacks appetite and sleep. = Postnatal depression

0209. A 30-year-old Primigravida at 17 weeks of gestation is known to have epilepsy and is on valproic acid. She was concerned about the possible risks to her baby. = Neural tube defect

0210. A 28-year-old Primigravida at 8 weeks of gestation is known to have chronic hypertension and presented to Antenatal Clinic. = Lisinopril

0211. A 28-year-old G4 P3 AO at 12 weeks of gestation with a prior history of preeclampsia and fetal growth restriction presented to the Antenatal Clinic. = Aspirin

0212. A 22-year-old G2 PO Al at 13 weeks of gestation presented to the Antenatal Clinic. In her first pregnancy, she had a painless fetal passage at 22 weeks. = Cervical cerclage

0213. A 30-year-old Primigravida is found to have hyperthyroidism during her pregnancy. = Radioactive iodine

0214. A 28-year-old Primigravida presented to the Antenatal Clinic for an Ultrasound scan. Ultrasound: Single viable fetus with significant lower levels of amniotic fluid (oligohydramnios). = Placental insufficiency

0215. A 36-year-old presented to the Antenatal Clinic for an Ultrasound scan. Ultrasound: Single viable fetus with significant increased levels of amniotic fluid (polyhydramnios). = Anencephaly

0216. A pregnant woman with prenatal diagnosis of Rhesus (Rh) alloimmunization had an ultrasound scan during follow-up. = Fetal ascites with skin edema

0217. A 23-year-old pregnant woman at 28 weeks of gestation. Ultrasound showed fetal hydrops with high peak systolic velocity more than 1.8 MOM in the middle cerebral artery Doppler. = Anti-kell antibodies

0218. A 30-year-old G2 Pl AO Ll at 33 weeks of gestation presented with decreased fetal movement. Obstetric ultrasound was performed. = BPS 8/10

0219. During duty in the Labor and Delivery Room, the nurse called to evaluate the cardiotocography of PG 39 weeks in active labor. The nurse asked about the relationship between the cause and type of deceleration. = Cord compression causes variable deceleration

0220. A 32-year-old PG at 25 weeks of gestation is complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. Examination demonstrates a positive Homan’s sign. = Compression ultrasonography

0221. A 28-year-old diabetic on insulin with no significant family history is concerned about pregnancy. = Fetal cystic fibrosis

0222. A 30-year-old PG at 30 weeks of gestation with severe preeclampsia complaining of right upper quadrant abdominal pain. = Tension of the liver capsule

0223. A 27-year-old G3 P2 AO L2 at 34 weeks of gestation with severe preeclampsia. = Decrease risk of maternal complications such as stroke

0224. A 30-year-old G4 P3 AO L3 at 34 weeks of gestation with severe preeclampsia. = Plasma volume

0225. A pregnant woman with preeclampsia has just delivered and has a lax uterus with moderate postpartum hemorrhage. Physical examination reveals no laceration or retained product of conception. = 20 units oxytocin in a 500 mL of D5W given intravenously

0226. A 30-year-old primigravida at 30 weeks of gestation newly diagnosed with preeclampsia. = Captopril

0227. A 22-year-old PG at 33 weeks of gestation newly diagnosed with gestational diabetes. = Diet

0228. A 21-year-old G2 Pl AO Ll at 18 weeks of gestation presented to the obstetric clinic for the first time. The obstetrician asked for an oral glucose tolerance test. = History of gestational diabetes in the previous pregnancy

0229. A 23-year-old PG at 28 weeks of gestation known case of tricuspid regurgitation complaining of slight limitation of physical activity. = Class II

0230. A 22-year-old pregnant woman at 40 weeks of gestation was diagnosed with DVT and started on a therapeutic dose of heparin. The patient had a normal vaginal delivery. Shortly after a heparin injection, she sustained postpartum hemorrhage. The uterus was contracted and examination revealed no lacerations. = Protamine sulfate

0231. A 32-year-old woman, primigravida, presented with shortness of breath during an antenatal visit. She was diagnosed with cardiac valve disease. = Mitral stenosis

0232. A 23-year-old primigravida admitted for induction of labor. The cervix is closed and 3.5 cm long. = Vaginal prostaglandin E2

0233. A 28-year-old G4 P3 AO at 40 weeks of gestation presented with irregular contractions. She was admitted to the Labor and Delivery Ward. = 8 hours

0234. A 22-year-old PG at 39 weeks of gestation admitted to the Labor Room with active labor. Initial cervical examination revealed 5 cm dilatation with 60% effacement and station was at -2. After 6 hours despite regular adequate contractions, abdominal examination revealed the presence of a retraction ring and vaginal examination showed cervical dilatation of 7 cm and station of -1. = Obstructed labor

0235. A 28-year-old PG presents at 34 weeks of pregnancy with constant abdominal pain and moderate bleeding. Her symphysiofundal height is 37 cm, and her uterus is tender and firm. CTG: Unprovoked decelerations. = Placental abruption

0236. A 29-year-old woman, G2, Pl, at 38 weeks of gestation comes to the Labor and Delivery Ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony-forming units/milliliter of Group-B streptococci and bronchial asthma, for which she uses a Ventolin inhaler. = Ampicillin

0237. A 30-year-old G4 P3 at 30 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complains of rigors and chills. Urine analysis: Numerous pus cells. = Pyelonephritis

0238. A 23-year-old G2 P1 at 40 weeks of gestation presented to the Emergency Room complaining of painful uterine contractions. Vaginal examination revealed cervical dilatation of 3 cm and 60% effacement. Upon admission to the Labor Room, she had a gush of clear fluid. = Spontaneous rupture of membranes

0239. A 22-year-old PG at 30 weeks of gestation presented to the Emergency Room complaining of lower abdominal pain. Vaginal examination revealed cervical dilatation of 2 cm with 50% effacement. She was admitted to the Labor and Delivery Room. The consultant on duty decided to start her on oxytocin antagonist (atosiban) as a tocolytic. = Delay labor to gain the maximum benefit from steroids

0240. A 39-year-old G4 P3 at 12 weeks of gestation came for an ultrasound study. Ultrasound: Single viable fetus with cystic hygroma. = Chorionic villus sampling

0241. A 32-year-old G2 Pi AO at 12 weeks of gestation. She is a known case of IDDM for 12 years and attended the Antenatal Clinic. = Congenital malformations

0242. A 28-year-old G2 P1 AO at 33 weeks of twin gestation presented to the Antenatal Clinic. Her investigations confirmed iron deficiency anemia. = Moderate and severe anemia

0243. A 25-year-old primigravida presents at 15 weeks of gestation to the antenatal visit where blood and urine investigations were requested. = 40-45% increase in total blood volume

0244. A 20-year-old nulliparous healthy married woman presents to the clinic requesting contraception. She has a history of menorrhagia and occasional dysmenorrhea. No family history of note. = Combined oral contraceptive pills

0245. A 26-year-old average-size woman has delivered a baby boy within the last 24 hours. During the morning round in the post-partum ward, it was found that her blood group is B-, her husband is O+, and her son is A+. A 300-g dose of anti-D immunoglobulin was prescribed. = 30 mL of fetal whole blood

0246. A 24-year-old primigravida at her 11th week of pregnancy presents with a history of lethargy, constipation, and intolerance to cold temperature. = Thyroxin

0247. A 36-year-old woman G2 P1 AO L1 at 32 weeks gestation presents for routine prenatal care. Past medical history is unremarkable. Current pregnancy has been uncomplicated, with occasional Braxton Hicks contractions and increasing non-pruritic vaginal discharge like cervical mucus. = Follow-up in 2 weeks

0248. A 26-year-old woman primigravida tested positive on a home pregnancy test. Her last menstrual period was 36 days ago, and she usually has a 30-day cycle. Three weeks ago, she received a rubella vaccine and was advised not to become pregnant for 2 months after the vaccine. = Favorable pregnancy outcome

0249. A 38-year-old primigravida at 35 weeks gestation complains of a mild headache and facial edema. Her reflexes are brisk, and she is suspected of having preeclampsia. = Proteinuria

0250. A 70-year-old married woman presents with a large prolapse. She has no other significant history except an abdominal hysterectomy at the age of 48 for heavy periods. Examination shows vaginal vault prolapse extending beyond the introitus and a very deficient perineum with a large vaginal opening. = Vaginal repair with sacrospinous fixation

0251. A 40-year-old G9 P6026 at 9 weeks’ gestation presents with vaginal spotting and mild abdominal pain. Ultrasound shows a 5-week gestational size and no fetal heart detected. = Conservative management

0252. A 26-year-old woman presented with insomnia, fatigue, and sadness. She delivered her first child 5 days ago. Examination reveals a tearful and depressed appearance. = Selective serotonin re-uptake inhibitors

0253. A 44-year-old P6006 woman had second-degree uterine descent and moderate cystorectocele. = Anterior colporrhaphy

0254. A 49-year-old morbidly obese woman presents with a history of pelvic organ prolapse. Her BMI is 48 kg/m². = Rectocele

0255. A 38-year-old primigravida at 33 weeks’ gestation is diagnosed with small for gestational age fetus and reversed end-diastolic flow on umbilical artery Doppler. = Antenatal steroids and delivery within 1 week

0256. A 23-year-old primigravida is admitted with threatened preterm labor at 30 weeks’ gestation and has received antenatal corticosteroids. = Respiratory distress syndrome

0257. A 30-year-old G3 P0020 at 17 weeks gestation is undergoing serial ultrasound assessments of cervical length due to a history of a previous second-trimester abortion. = Cervical length less than 25 mm

0258. A 26-year-old primigravida at 23 weeks’ gestation presents for an ultrasound scan after a small amount of vaginal bleeding. The scan shows a viable fetus and a cervical length of 20 mm. = Conservative management

0259. A 27-year-old primigravida with a low-risk pregnancy is admitted at 32 weeks with antepartum hemorrhage and diagnosed with placental abruption. Bleeding settled with conservative management. = Reclassify as “High Risk” pregnancy care with serial ultrasound for fetal growth

0260. A 25-year-old primigravida at 34 weeks’ gestation presents with generalized pruritus and yellowish discoloration of the sclera and skin. = Bile acids and liver function tests

0261. A 19-year-old primigravida is referred at 32 weeks’ gestation due to raised blood pressure. = Admit and commence antihypertensive treatment

0262. A 20-year-old primigravida at 8 weeks’ gestation is known to have sickle cell disease, while her husband has normal hemoglobin. She has not taken any vitamin supplements so far. = 5 mg immediately throughout pregnancy

0263. A 22-year-old primigravida with Type 1 diabetes presents at 32 weeks’ gestation with regular painful contractions and a closed cervix. = Steroids, additional insulin, and tocolytic agent

0264. A 40-year-old nulliparous woman attends a preconception counseling session after being treated for breast carcinoma. She plans a pregnancy. = 2 years

0265. A 30-year-old woman with known sickle cell trait attends an antenatal booking clinic at 8 weeks’ gestation. = Urinary tract infection

0266. A 36-year-old G4 P3003 is admitted in preterm labor at 36+5 weeks with polyhydramnios. Fetal bradycardia is noted after spontaneous rupture of membranes. = Cord prolapse

0267. A 36-year-old G3 P2002 with 2 previous caesarean sections is diagnosed with major placenta previa and placenta accreta at 32 weeks’ gestation. = 36-37 weeks

0268. A 40-year-old G4 P2012 at 41+5 weeks had undergone induction of labor by prostaglandin in the last 6 hours. She suddenly developed vaginal bleeding and shock. = Ruptured uterus

0269. A 40-year-old G4 P30Q3 at 32 weeks’ gestation presented to the hospital with right upper quadrant pain. = Hepatic capsule distension

0270. A 34-year-old healthy woman presents with recurrent symptoms, including headache, anxiety, and mastalgia, that start 8-10 days before menstruation and improve afterward. = Premenstrual tension syndrome

0271. A 26-year-old woman primigravida at 16 weeks’ gestation presents to the clinic complaining of nausea and vomiting. = Folate deficiency

0272. A 30-year-old G4 P3003 woman at 39 weeks’ gestation delivered a baby boy weighing 30.5 kg. Upon delivery of her placenta, an inverted uterus was noted and successfully reduced. = Fundal

0273. A 25-year-old woman underwent a normal vaginal delivery at term. After 30 minutes, the placenta is still in place. = Attempt manual extraction of the placenta

0274. A 37-year-old woman G4 P3003 at 40 weeks’ gestation presents in labor and progresses to vaginal delivery. Placenta delivery is complicated with inverted uterus and 1200 cc of vaginal bleeding. = Inadequate effect of the myometrial contractions

0275. A 25-year-old primigravida at 35 weeks’ gestation presents with spontaneous rupture of membranes and undergoes augmentation of labor with parenteral oxytocin. Fetal monitoring shows distress. = Ceasing the oxytocin to improve placental perfusion

0276. A 27-year-old woman primigravida has severe uterine bleeding that exceeds 700 cc after a normal vaginal delivery which does not respond to medical treatment. The obstetrician in charge decided to go for surgical management. The patient desires future pregnancies. = Internal iliac artery

0277. A 30-year-old GS P3013 woman presented in labor at term. She had a vaginal delivery complicated by abruption placenta. She was then noted to have significant uterine bleeding. The team in charge noted she had bleeding from multiple venipuncture sites. = Coagulopathy correction

0278. A 25-year-old G2 POO1O at 33 weeks’ gestation referred to the hospital with a BP of 160/110 mmHg on a routine appointment. Her BP at her first booking visit at 8 weeks was 124/70 mmHg with trace proteinuria. Further detailed history revealed that she was also complaining of headaches with no history of migraines. She was started on antihypertensives and magnesium sulfate along with steroid injections (see lab results). = Immediate induction of labor for anticipated vaginal delivery

0279. A 35-year-old G9 P6026 at 8 weeks’ gestation presents to the hospital with vaginal spotting associated with very mild lower abdominal pain. She has noticed some dark brown clots. Examination reveals she is comfortable in bed with no abdominal tenderness appreciated. Pelvic examination reveals minimal dark-red clots in the introitus and cervical os closed (see report). Transvaginal ultrasound: 5-week gestational size with no fetal heart. = Expectant management

0280. A 27-year-old G4 P2103 woman presents at 37 weeks’ gestation with moderately severe vaginal bleeding (see image and report). Ultrasound: 32 weeks’ gestation, with low-lying placenta covering part of the cervix. = Cesarean delivery

0281. A 23-year-old woman primigravida presents at 27 weeks’ gestation with vaginal bleeding. She undergoes a transvaginal ultrasound showing a placenta previa. = Postcoital vaginal spotting

0282. A 32-year-old nulligravid healthy woman presents for a routine visit. Physical examination is entirely normal. She is a heavy cigarette smoker. She undergoes colposcopy and cervical biopsies (see reports). Pap smear: High grade squamous intraepithelial lesion (HSIL). Cervical biopsies: Squamous cell carcinoma in situ (CIS). After counseling about her condition, she wants to preserve her fertility if her status allows. = Cold knife cone biopsy

0283. A 42-year-old P3003 healthy woman presents with heavy prolonged vaginal bleeding over the past 7 months. Her periods have become longer and progressively heavier, with the last one occurring 15 days ago. Pelvic examination reveals a small amount of blood in the vaginal vault, normal-sized uterus, and mobile ovaries. (See reports.) Pelvic ultrasound: Endometrium 13 mm and a 2.2 cm x 1 cm lesion in the uterine cavity. Endometrial biopsy: Normal histology. = Sonohysterogram

0284. A 42-year-old P3003 healthy woman presents with a history of heavy and prolonged vaginal bleeding over the past 7 months. Her periods have become longer and progressively heavier. Her LMP was 15 days ago. Pelvic examination reveals a small amount of blood in the vaginal vault, a normal-sized uterus, and mobile ovaries. Pelvic ultrasound: 2.5 cm x 1.5 cm lesion in the uterine cavity. = Endometrial polyp

0285. A 58-year-old woman P2002 presents with a history of heaviness in the pelvis, discomfort, and abdominal distension over the last 6 months. Examination reveals a distended abdomen with significant discomfort on palpation and a large abdominopelvic mass. (See report.) Ultrasound and CT: A 12 cm left ovarian mass, ascites, and thickening of the peritoneum. = Surgery followed by chemotherapy

0286. A 24-year-old woman primigravida undergoes an uneventful vaginal delivery at term. After placental delivery, she has 1000 cc of vaginal bleeding. She is alert, and her vital signs are stable, with the uterus noted to be firm. = Genital tract laceration

0287. A 39-year-old G8 P5126 at 38 weeks’ gestation presents for induction of labor due to decreased fetal movement. She is started on oxytocin and begins having contractions. After several hours of labor, her cervix dilates to 6 cm, but she then develops a fever and fetal tachycardia. A diagnosis of chorioamnionitis is entertained. She delivers a baby boy vaginally 4 hours later, but afterward, there is a large continuous vaginal bleeding. = Uterine atony

0288. A 30-year-old woman had a spontaneous vaginal delivery for a term twin pregnancy 2 hours ago. Now she has active vaginal bleeding. = Uterine atony

0289. A 38-year-old woman, known for low-lying placenta, delivered a normal vaginal delivery. One hour post-delivery, she had postpartum hemorrhage. = Uterine atony

0290. A 24-year-old woman just delivered her first baby with a birth weight of 2.7 kg while she was at 38 weeks of gestation. She is not known to have any medical or surgical history. She has a heavy gush of bleeding postpartum. = Uterine atony

0291. A 50-year-old woman (P5005) presents to the clinic complaining of urine leakage while coughing and sneezing. She denies any frequency, dysuria, or urgency. = Hypermobile urethra

0292. A 64-year-old otherwise healthy woman presents with a history of constipation and difficulty with defecation. She reports using her fingers to push her vagina backward to pass bowel motions. = Posterior colporrhaphy

0293. A 58-year-old woman (P6006) presents with a 2-month history of pelvic heaviness and a sensation of lower pelvic pressure. Examination reveals vulvar atrophy, mucosal bulging through the introitus, and the rest of the pelvic examination is within normal limits. = Enterocele

0294. A 44-year-old woman (P5005) presents to the clinic with an uncomfortable sensation in the vagina for the last year. She reports pelvic pressure associated with urinary frequency but no urinary leaks or irregular menstruation. Obstetric history includes 5 term spontaneous vaginal deliveries. She works in loading and unloading heavy boxes. Examination reveals a large bulging of the anterior vaginal wall. = Anterior colporrhaphy

0295. A 54-year-old menopausal woman presents with a history of involuntary urine leaks with urgency. The complaint occurs at any time during the day or night, without warning. There is no clear association between leaks and any specific activity, with occasional association with coughing and laughing. Physical examination is unremarkable. Urinalysis and culture are negative. Urodynamic study shows spontaneous bladder contractions even with small bladder filling. = Anticholinergics

0296. A 62-year-old postmenopausal woman (P4014), known diabetic and with congestive heart failure, is referred by a Cardiology Clinic. She has occasional incontinence with coughing and sneezing. During the interview, she also complains of lower abdominal heaviness and vaginal bulging. Pelvic examination reveals second-degree pelvic prolapse. = Vaginal pessary

0297. A 45-year-old healthy woman (P4004) presents with a complaint of urine leaks when she laughs, coughs, or sneezes. She denies any history of frequency, dysuria, nocturia, or hematuria. She does not report urge voiding when hearing running water. Her symptoms are embarrassing and inconvenient. = Kegel exercises

0298. A 13-year-old healthy girl is brought by her mother with concerns about not yet starting menstruation. Examination reveals sparse hair covering the labia majora, not extending onto the mons pubis. She has developed breast buds and papilla and areolar enlargement, with no separation in contour between the breast and areola. = Tanner stage II

0299. A 30-year-old woman is referred by a medical clinic with a complaint of vulvar pain. Examination reveals one ulcer on the left lower labia majora. The lesion has a ragged edge, necrotic base, and palpable adenopathy on the left inguinal region. = Chancroid

0300. A 36-year-old woman (G4 P2103) at 23 weeks’ gestation presents with a primary attack of herpes simplex virus infection. Acyclovir is given orally for 10 days. = Decrease viral shedding and current infection duration

0301. A 34-year-old G2 P1001 at 33 weeks gestation presents with vaginal bleeding associated with clots. No abdominal pain or labor-like pain has been reported. Ultrasound: The placenta is covering the cervical internal os. = Multigestation

0302. A 29-year-old woman presented in labor at 41 weeks’ gestation and progressed well to vaginal delivery. The placenta did not deliver spontaneously. A manual extraction of the placenta was attempted but failed, with the impression of adherent placenta to the uterus. The patient opted to keep her uterus. The placenta was ligated with suture as high as possible in the uterus, and she was placed on methotrexate treatment. = Infection

0303. A 30-year-old married, nulligravid woman with symptomatic multiple uterine fibroids, all subserosal, underwent myomectomy. According to her operative note, the endometrial cavity was entered during surgery. = Not affected

0304. A 22-year-old primigravida presents to the Emergency Room at 10 weeks’ gestation with severe left lower quadrant abdominal pain. Preliminary diagnosis is ruptured ectopic pregnancy. All her vital signs are within normal limits. Transvaginal ultrasound: Moderate free fluid in the abdominal cavity. = Tachycardia

0305. A 24-year-old primigravida presents at 12 weeks gestation to an antenatal visit. Blood electrolytes and renal function tests were requested 3 days earlier. = A fall in serum creatinine level

0306. A 35-year-old G3 P2002 woman presents to the clinic near term. Ultrasound demonstrates that the fetal head is in the fundus, the fetal spine is parallel to the mother’s spine, with extended knees and flexed hips. Both arms are flexed at the elbows. = Frank breech

0307. A 37-year-old G3 P1011 at 28 weeks’ gestation had vaginal spotting 2 weeks ago but no abdominal cramping or passing any clots or tissue. Examination reveals fundal height equivalent to 18 weeks’ size. Ultrasound confirms lack of fetal heart activity and no fetal movement. = Fetal demise

0308. A 25-year-old woman, known to have a left ovarian cyst, presented to the Emergency Room with 3 hours of severe left lower quadrant pain associated with nausea. Ultrasound Doppler: Diminished blood flow toward the left ovary. = Laparoscopic ovarian cystectomy

0309. A 55-year-old woman presents with on-and-off vaginal bleeding. She is menopausal for 3 years and has been taking conjugated estrogen pills. There is no previous surgical history. = Add progesterone therapy

0310. A 33-year-old single woman was found to have a uterine fibroid incidentally on pelvic ultrasound. Ultrasound: Subserosal uterine fibroid measuring 5×5 cm. = Conservative

0311. A 33-year-old woman presents with a complaint of a heavy menstrual cycle. During examination, a firm fundal mass was felt. = Pelvic ultrasound

0312. A 25-year-old pregnant woman with 7 weeks’ amenorrhea presented to the clinic with a history of passing tissue at home and vaginal bleeding. Examination revealed mild vaginal bleeding with a closed cervix. = Complete

0313. A 33-year-old 7 weeks’ pregnant woman presented with mild vaginal bleeding. Examination revealed a closed cervix. Ultrasound: A 7-week viable intrauterine pregnancy. = Threatened

0314. A 17-year-old primigravida presents to the clinic for the first time, missing her period. LMP was 9 weeks ago, and she had a positive home pregnancy test. Pelvic examination reveals a closed cervical os with mild bleeding. Transvaginal ultrasonography: Intrauterine gestational sac with a crown-rump length of 9 weeks of gestation with positive embryonic heartbeat. = Threatened

0315. A 25-year-old pregnant woman presented with abdominal cramps and mild vaginal bleeding. Examination revealed an open cervix with mild bleeding. Ultrasound: A 7-week viable intrauterine pregnancy. = Inevitable

0316. A 25-year-old pregnant woman presented with a history of vaginal bleeding and passed tissue at home. Examination revealed an open cervix. Ultrasound: Intrauterine tissue. = Incomplete

0317. A 33-year-old 7 weeks’ pregnant woman presented with vaginal bleeding and a history of passing tissue at home. Examination revealed an open cervix with moderate vaginal bleeding. Ultrasound: Intrauterine 3×4 cm tissue seen. = Evacuation of the uterine cavity

0318. A 30-year-old 7 weeks’ pregnant woman presented with mild vaginal bleeding. Examination revealed a closed cervix. Ultrasound: 7 weeks’ viable intrauterine pregnancy. = Conservative

0319. A 30-year-old 33 weeks’ pregnant woman presented to the Emergency Room with lower abdominal pain and vaginal bleeding. = Insert 2 large gauge IV lines

0320. A 33-year-old 32 weeks’ pregnant woman presented to the Emergency Room with mild painless vaginal bleeding. = Localize the placenta by ultrasound

0321. A 35-year-old woman is complaining of vaginal discharge and burning with urination. Her husband was recently diagnosed with gonorrhea. = Endocervical swab

0322. A 30-year-old woman is complaining of yellowish, fishy-smelling vaginal discharge and itching. = Bacterial vaginosis

0323. A 25-year-old woman is complaining of whitish vaginal discharge and itching for 3 days. = Vaginal candidiasis

0324. A 53-year-old woman, whose last menstrual period was 18 months ago, is complaining of dyspareunia for the past few months. = Conjugated estrogen cream

0325. A 60-year-old menopausal woman presents with recent on-and-off vaginal bleeding. = Endometrial atrophy

0326. A 50-year-old woman is complaining of hot flashes and insomnia. = Lifestyle modification

0327. A 35-year-old smoker man and a 26-year-old woman presented with primary infertility for 3 years. The wife had 3 cycles of Clomid as a case of polycystic ovaries. = Seminal analysis

0328. A 20-year-old woman presented with a history of primary infertility for 1 year. She had a history of scanty irregular cycles with prolonged intervals (see lab results). = Chromosomal analysis

0329. A 28-year-old woman presented with a history of secondary infertility for 4 years (see image). = Endometriosis

0330. A 35-year-old woman diagnosed with left tubal ectopic pregnancy was treated with methotrexate. She remained asymptomatic with a plateauing of Beta hCG on day 4 and day 7. = Second dose of methotrexate

0331. A 43-year-old woman presented with intermenstrual bleeding in the last 3 months (see report). Ultrasound: A 13 mm long echogenic structure in the endometrium. = Hysteroscopy and removal of the structure

0332. An 18-year-old girl complains of severe lower abdominal pain and back pain on the first 2 days of her cycle every period. She has a regular cycle and is medically free. = NSAIDs

0333. An 18-year-old girl complains of severe lower abdominal pain and back pain on the first 2 days of her cycle every period. She has a regular cycle and is medically free. Tried NSAID but no improvement was noticed. = Oral contraceptive pills

0334. A 26-year-old woman, her menarche was at the age of 15 years. Her last cycle was 9 months ago (see lab results). = Premature ovarian insufficiency

0335. A 30-year-old woman G0P0 presented with a history of infertility for 3 years (see lab results). = Bromocriptine

0336. A 30-year-old woman married for 3 years with a history of an irregular cycle. Her husband’s seminal analysis was normal. = Ovulatory dysfunction

0337. A 30-year-old 12 weeks pregnant woman presented to the Emergency Room with vaginal bleeding. Examination revealed her fundal height is consistent with 19 weeks (see report). Ultrasound: Findings are consistent with molar pregnancy. = Suction and evacuation

0338. A 50-year-old woman with a history of involuntary urine leak, especially when she runs. = Cough test

0339. A 50-year-old woman presented with a right ovarian mass. Examination revealed abdominal ascites. Her epithelial tumor marker is high. = Surgical

0340. A 60-year-old woman presented with urinary tract infection for the second time in the last 6 months. She is feeling vaginal bulging and has difficulty emptying her bladder completely. = Post-void residual volume

0341. A 40-year-old woman complaining of frequency and urgency for 1 month. A suspicion is raised of overactive bladder syndrome. = Urine culture

0342. A 30-year-old woman presented with a history of recurrent urinary tract infections. She notices it happening after sexual intercourse. = Postcoital single-dose antibiotic

0343. An 80-year-old woman known case of prosthetic heart valve on warfarin and bedridden. Diagnosed as stage 3 pelvic organ prolapse. = Pessary

0344. A 40-year-old woman diagnosed with stress urinary incontinence. During counseling, she wants the most effective treatment for her condition. = Midurethral sling

0345. A 25-year-old woman received the first dose of the human papilloma virus vaccine 3 months ago and visited the clinic today. = Give the second dose today

0346. A 30-year-old woman underwent ovarian cystectomy. While the nurse was preparing the specimen to be sent to histopathology, there was a leak of thick fatty material from the cyst. = Cystic teratoma

0347. A 60-year-old woman presented with a history of intermittent vaginal bleeding over the last 2 months. There is no history of weight loss. No past surgical or medical history, and she is not on any medication. = Endometrial atrophy

0348. A 60-year-old woman with a history of intermittent vaginal bleeding (see report). Ultrasound: Endometrial thickness of 8 mm and ovaries detected. = Clinical endometrial biopsy

0349. A 30-year-old woman presented with a history of the absence of her period for the last 3 months. = Pregnancy test

0350. A 23-year-old single woman presented with heavy menstruation during the first 4 days of her period for the last 2 years (see image and lab results). = Uterine leiomyomas

0351. A 43-year-old woman with a history of pulmonary embolism 3 years ago is seeking an effective family planning method. = Intrauterine device

0352. A 23-year-old single girl diagnosed with a 5*5 cm uterine leiomyoma incidentally during a kidney ultrasound. = Conservative

0353. A 35-year-old woman with a leiomyoma associated with heavy menstruation (see image and lab result). = Correct the anemia

0354. A 35-year-old woman is complaining of severe abdominal pain. She is a known case of primary infertility and underwent embryo transfer 3 weeks ago (see lab results). = Ectopic pregnancy

0355. A 30-year-old woman presented with intermenstrual vaginal bleeding for 5 days. = Beta hCG

0356. A 46-year-old woman is complaining of heavy menstruation lasting for 14 days every period. She is morbidly obese and has type 2 diabetes mellitus (see lab results and report). Ultrasound: Endometrial thickness of 18 mm. = Clinical endometrial sample

0357. A 44-year-old woman presented with heavy vaginal bleeding (see lab results). = Dilatation and curettage

0358. A 30-year-old woman diagnosed with endometriosis tried non-steroidal anti-inflammatory agents but is still symptomatic. = Oral progesterone therapy

0359. A 33-year-old woman, nulliparous, complaining of cyclic pelvic pain and dyschezia underwent diagnostic laparoscopy (see image). = Endometriosis

0360. A 45-year-old woman P6 is complaining of chronic pelvic pain and heavy menstruation (see report). Pelvic MRI: Diffuse thickened myometrium. = Hysterectomy

0361. A 45-year-old woman presented to the clinic complaining of postcoital bleeding. Pelvic examination revealed a 2*1 cm cervical mass. = Punch biopsy

0362. A 26-year-old 9 weeks pregnant woman, presented with vaginal bleeding and subsequently had a spontaneous abortion. = Chromosomal abnormality

0363. A 32-year-old woman presented to the Gynecology Clinic with dysmenorrhea. = Menstrual

0364. A 10-week pregnant woman presented to the Emergency Room with a history of abdominal cramping and vaginal bleeding. She passed some tissue at home. Examination revealed normal vital signs with a closed cervix (see report). Ultrasound: Shows an empty uterus. = Reassure her

0365. A 20-year-old woman came to the clinic for prenatal care. She missed her period for the last 6-8 weeks. Home pregnancy test was positive 2 weeks back and negative before that. Her periods were irregular and she is unsure of the last day of her menstrual period. = Ultrasound now

0366. A 25-year-old woman presented to the clinic for antenatal care. Her last period was 6 weeks back. She is spotting on and off with no pain (see lab result and report). Transvaginal Ultrasound: No intrauterine pregnancy seen. = Repeat BhCG level in 48 hours

0367. A 29-year-old woman presented to the clinic unsure of her gestational age. She missed her period 3 months ago but her periods are irregular (see report). Ultrasound: Determined gestational age as 11 weeks. = Crown-rump length

0368. An 18-year-old G2 P1 presents for her first antenatal visit. The first day of her last menstrual period is May 7th. Her periods are regular, and she is sure about her periods. = February 10 next year

0369. A 19-year-old G1 P0 at 42 weeks is admitted for induction of labor. Her antenatal care was uncomplicated. Examination revealed the cervix was closed and long. Prostaglandin E2 is placed vaginally. An hour later, she started to contract regularly, and the fetal heart dropped to 70 bpm and was not recovering. Her vaginal examination showed a fully dilated cervix and presenting part at +2. = Start pushing and consider applying ventouse

0370. A 28-year-old woman had a spontaneous abortion at 8 weeks. She is concerned regarding the cause of her abortion. = Chromosomal abnormalities

0371. A 28-year-old pregnant woman presented at 20 weeks with spotting. No history of trauma. Her blood group is O negative (see report). Ultrasound: Normal-sized fetus, normal placentation, and long cervix. = Give anti-D

0372. A 26-year-old woman presented to the clinic pregnant at 15 weeks. She is known to have epilepsy and is taking Phenytoin. The last convulsion was 6 years ago. = Continue the same medication

0373. A 30-year-old woman in her first pregnancy. She is 20 weeks pregnant and known to have SLE. She has been symptom-free for the past 2 years. She is taking Plaquenil daily. = Continue the medication

0374. A 30-year-old woman delivered her first baby 3 weeks ago and presented to the Emergency Room with fever, chills, and breast pain. Examination revealed the right breast is red, enlarged, and tender, with no fluctuation found (see lab result). = Antibiotics to cover Staphylococcus aureus and do breast ultrasound to rule out abscess

0375. A 28-year-old woman presented with mild pelvic pain and spotting. She was diagnosed with an ectopic pregnancy and offered medical management. = Methotrexate

0376. A 25-year-old pregnant woman in her 10th week presented with spotting and pain. Examination revealed the uterus was larger than expected and pelvic examination showed vesicles passing through the internal os. = Serum BhCG level and ultrasound

0377. A 26-year-old woman pregnant at 10 weeks was diagnosed with a molar pregnancy. After evacuation and curettage, she has been followed weekly with BhCG levels. The levels have not changed for the past month. = Referral to oncology, consider methotrexate

0378. A 45-year-old woman presented to the Emergency Room complaining that her period has not stopped for the past 15 days. Now she is feeling drowsy and easily fatigued and sometimes faints. = Complete blood count and BhCG

0379. A 45-year-old woman presented to the Emergency Room complaining that her period has not stopped for the past 15 days and now she is feeling drowsy and easily fatigued (see lab results). = Start blood transfusion

0380. A 45-year-old woman came to the clinic complaining of heavy periods lasting more than 10 days. Pregnancy test is negative and ultrasound is normal. = Tranexamic acid

0381. A 23-year-old woman came to the clinic complaining of severe pain the day prior to menses, continuing for 2 days. The pain is so severe that she misses work. = Combined hormonal contraceptive pills

0382. A 30-year-old woman married for 3 years has been off contraceptive pills for the last 18 months and has not gotten pregnant. = Infertility investigation for her and her husband

0383. A 28-year-old woman 2 weeks postpartum came to the clinic asking for contraception. She is exclusively breastfeeding. = Combined oral contraceptive pills

0384. A 28-year-old primigravida came to the clinic at 38 weeks for a regular check-up. Her blood pressure was 170/110 mmHg. A urine dipstick showed +3 protein. Her blood work was taken, and she was sent to the labor and delivery room. = Magnesium sulfate

0385. A 22-year-old G2 P1 A0 L1 at 33 weeks of gestation with severe preeclampsia. = Magnesium sulfate

0386. A 25-year-old woman in her first pregnancy presented to the Emergency Room at 35 weeks with headache, blurred vision, and abdominal pain. Examination shows her cervix is 2 cm dilated, 75% effaced, and she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive (see lab results). = Start magnesium sulfate

0387. A 20-year-old woman in her first pregnancy came to the clinic at 32 weeks for a regular antenatal visit. She has gestational diabetes on insulin and is non-compliant with her medication. Her anatomy scan at 20 weeks was normal, and her fundal height is 38 cm. = Polyhydramnios

0388. A 26-year-old woman in her first pregnancy came to the clinic. Her last menstrual period is unknown. = Crown-rump length

0389. A 31-year-old woman presented with a positive pregnancy test to the antenatal clinic. She is not sure of her last menstrual period as she is lactating. Pelvic ultrasound was requested for dating her pregnancy. = Crown-rump length

0390. A 29-year-old woman presented to the Emergency Room with a very heavy period. She is morbidly obese and diabetic. Her periods are irregular, occurring every 3-4 months. She had her period 2 weeks ago and it has not stopped, with heavy clots. Pregnancy test is negative. = Chronic anovulation

0391. A 21-year-old woman pregnant at 8 weeks is diagnosed with a missed abortion. = Misoprostol

0392. A 20-year-old woman presented to the clinic with dysuria and suprapubic pain. No fever. Urine dipstick done (see lab results). = Start empiric treatment

0393. A 28-year-old G1 P0 woman presented to the Emergency Room at 30 weeks gestation with abdominal pain with no leaking or bleeding. The CTG shows a normal heart rate with regular contractions 4 in 10 minutes. She was admitted with preterm labor, as her cervix was 2 cm dilated and 80% effaced. = Dexamethasone, nifedipine, GBS prophylaxis

0394. A 25-year-old G1 P0 woman presented to the Emergency Room at 30 weeks gestation with abdominal pain. There was no leaking or bleeding. The CTG shows a normal heart rate with regular contractions 4 in 10 minutes. = Digital exam for cervical dilation

0395. A 30-year-old woman in her first pregnancy had an ultrasound confirming Monochorionic Diamniotic twins. = 4-8 days

0396. A 30-year-old woman in her first pregnancy had an ultrasound confirming Monochorionic Monoamniotic twins. = 9-12 days

0397. A 30-year-old woman in her first pregnancy had an ultrasound confirming Dichorionic Diamniotic twins. = 0-72 hours

0398. A 35-year-old woman presented to the clinic for preconception counseling. She is known to have hypertension and is on ACE inhibitors. = Switch to alternative antihypertensive due to fetal kidney teratogenicity

0399. A 32-year-old woman G2 P1 L1. She is 39 weeks pregnant with normal prenatal care, presented to the Emergency Room with headache and blurred vision (see lab results). = Admit her for delivery

0400. A 15-year-old woman presented to the Emergency Room with pelvic pain and spotting. After reassessment, she was diagnosed with inevitable abortion and management options were given to her. After 15 minutes, she started to have severe bleeding and lost consciousness (see table). = Dilatation and curettage

0401. A 25-year-old pregnant woman in her 8th week presented to the Emergency Room with bleeding and reported passing vesicles. After assessing, her uterine size appears larger than the date. = Molar pregnancy

0402. A 25-year-old pregnant woman presented to the Emergency Room with spotting and passing vesicles (see lab result and report). Ultrasound: Snowstorm appearance. = Suction evacuation

0403. A 30-year-old woman G2 P1 L1 presented 3 days ago to the Emergency Room at 30 weeks gestation with preterm premature rupture of membranes. She was managed conservatively, and today she started to have fever and abdominal pain. = Ampicillin, Gentamicin, and deliver the patient

0404. A 30-year-old woman G2 P1 L1, post-date with dates confirmed by early scan, followed up weekly with normal CTG and amniotic fluid index. Her doctor planned for induction of labor. = Prostaglandin E2

0405. A 30-year-old woman G2 P1 L1, pregnant with twins, presented to the Emergency Room at 35 weeks with headache, blurred vision, and abdominal pain. There was no leaking or bleeding. CTG showed normal heart rate and no contraction (see lab results). = Preeclampsia

0406. A 30-year-old woman G2 P1 L1, pregnant with twins, presented to the Emergency Room at 35 weeks with headache, blurred vision, and abdominal pain. After assessment, CTG showed a normal heart rate with no contractions (see lab result). = Multiple gestations

0407. A 25-year-old woman G2 P1 L1, pregnant with twins, presented to the Emergency Room at 35 weeks with headache, blurred vision, and abdominal pain. After assessment, she started to have a grand mal seizure (see lab result). = Eclampsia

0408. A 30-year-old woman G2 P1 L1, pregnant with twins, presented to the Emergency Room at 35 weeks with headache, blurred vision, and abdominal pain. After assessment, she started to have a grand mal seizure (see lab result). = Delivery after stabilization

0409. A 30-year-old woman G2 P1 L1, 41 weeks pregnant confirmed dating with an early scan, started to follow up weekly with CTG twice a week. Her CTG showed deceleration with no signs of labor. = Delivery

0410. A 19-year-old G1 P0 at 41 weeks and 4 days was admitted for induction of labor. Her antenatal care was uncomplicated. Examination revealed her cervix was closed and long. Prostaglandin E2 was placed vaginally. An hour later, she started to contract regularly, and the fetal heart dropped to 70 beats per minute and was not recovering with fluid and oxygen administration. = Take her for cesarean section

0411. A 30-year-old woman G2 P1 L1 presented to the Emergency Room at 30 weeks gestation with profuse vaginal bleeding and abdominal pain. CTG showed a normal heart rate with regular contractions. = Placental abruption

0412. A 30-year-old woman G2 P1 L1, who has been missing her clinic appointments, presented to the Emergency Room at 30 weeks gestation with profuse vaginal bleeding. She had no pain, and the baby was moving well. CTG showed a normal heart rate with no contractions. = Placenta previa

0413. A 30-year-old woman G2 P1 L1, whose last menstrual period was 7 weeks ago, presented to the Emergency Room with lower abdominal pain and moderate vaginal bleeding, passing tissue. Examination revealed an open cervix with tissue seen at the cervix. = Incomplete abortion

0414. A 30-year-old woman G2 P1 L1, whose last menstrual period was 7 weeks ago, presented to the Emergency Room with lower abdominal pain and vaginal spotting. Examination revealed a tender abdomen and a closed cervix (see lab results and report). Bedside ultrasound: No intrauterine pregnancy seen and moderate intra-abdominal fluid seen. = Ectopic pregnancy

0415. A 30-year-old woman G2 P1 L1, whose last menstrual period was 7 weeks ago, presented to the Emergency Room with lower abdominal pain and vaginal spotting. Examination revealed a tender abdomen and a closed cervix (see report). Bedside Ultrasound: No intrauterine pregnancy seen and moderate intra-abdominal fluid seen. = BhCG quantitative

0416. A 25-year-old woman G1 P0 presented to the Emergency Room at 30 weeks gestation with regular uterine contractions. She had no vaginal bleeding or leaking. CTG showed a normal heart rate and four contractions in 10 minutes. = Perform a vaginal exam to assess cervical dilation

0417. A 25-year-old woman G1 P0 presented to the Emergency Room at 30 weeks gestation with vaginal leaking. Detailed history and physical examination confirmed preterm premature rupture of membranes. Her CTG showed a normal heart rate with no contractions. = Erythromycin + ampicillin + dexamethasone

0418. A 36-year-old woman G4 P3 L2, whose previous pregnancies were delivered normally without complications, had an uneventful pregnancy and went into spontaneous vaginal delivery after 5 hours of labor. She delivered a baby boy weighing 4600 g and, after placental delivery, started to bleed heavily. = Macrosomic baby

0419. A 36-year-old woman G4 P3 L2, whose previous pregnancies were delivered normally, had an uneventful twin pregnancy and went into spontaneous vaginal delivery after 5 hours of labor. She delivered healthy twin boys weighing 2800 g and 2900 g. After placental delivery, she started to bleed heavily. = Multiple gestation

0420. A 32-year-old woman G4 P3 L2 had normal deliveries with no prenatal or postnatal complications. She had an uneventful pregnancy and went into spontaneous vaginal delivery after 16 hours of labor. She delivered a healthy boy weighing 3000 g. After placental delivery, she started to bleed heavily. = Prolonged labor

0421. A 32-year-old woman G7 P6 L6 had normal deliveries with no prenatal or postnatal complications. She had an uneventful pregnancy and went into spontaneous vaginal delivery after 7 hours of labor. She delivered a healthy boy weighing 3000 g. After placental delivery, she started to bleed heavily. = Grand parity

0422. A 31-year-old woman G2 P1 L1 had an uneventful pregnancy and a spontaneous vaginal delivery after 2 hours of labor, just making it to the hospital. She delivered a healthy boy weighing 3000 g. After placental delivery, she started to bleed heavily. = Precipitous labor

0423. A 31-year-old woman G2 P1 L1 had an uneventful pregnancy and went into spontaneous vaginal delivery. She delivered a healthy boy weighing 3000 g. After placental delivery, she started to bleed heavily. = Call for help and make sure there is cross-matched blood

0424. A 31-year-old woman G2 P1 L1 had an uneventful pregnancy and went into spontaneous vaginal delivery. She delivered a healthy boy weighing 3000 g. After placental delivery, she started to bleed heavily. = Misoprostol

0425. A 25-year-old woman G1 P0 presented to the Emergency Room at 30 weeks gestation with vaginal leaking. After taking detailed history, she mentioned that it was a large amount of fluid and it is still ongoing. = Perform a sterile speculum examination

0426. A 30-year-old woman G2 P1 L1 presented 3 days ago to the Emergency Room at 30 weeks gestation with preterm premature rupture of membranes. She was managed expectantly and today she started to have fever and abdominal pain. = Chorioamnionitis

0427. A 26-year-old G4 P3 presented at 31 weeks gestation with labor pain. She had preterm premature rupture of membranes 4 weeks ago. Today, the cervix is 3 cm dilated with clear liquor noted. = High vaginal swab for bacterial culture and sensitivity

0428. A 31-year-old woman G2 P1 was admitted at 41 weeks gestation in active labor. She had received pethidine and promethazine earlier. The cervix is 9 cm dilated, and meconium-stained liquor is draining. Non-stress test done shows no abnormalities. = Change the position of the patient

0429. A 25-year-old woman was admitted at 36 weeks gestation in labor. Fetal monitoring trace shows late decelerations. = Hydrate, reposition, and review in 20 minutes

0430. A 60-year-old woman presents for a routine gynecology checkup. She is asymptomatic, but an incidental finding of grade 3 posterior vaginal wall prolapse was detected. She denies any symptoms related to urine or stool incontinence. = Conservative and reassurance

0431. A 90-year-old woman, diabetic and hypertensive, is admitted with heart failure, controlled on medications. An incidental finding of uterine procidentia was detected. The patient states that she has had this condition for over 10 years but it has never bothered her. She pushes the uterus back into place to help with urination and defecation. = Vaginal pessary

0432. A 50-year-old woman para 5 attends the clinic complaining of mild pelvic pressure symptoms. She denies any urinary, fecal, or gas incontinence. Examination reveals grade 2 posterior vaginal wall prolapse. = Pelvic floor exercise, reassurance, and follow-up

0433. A 50-year-old woman was managed conservatively for the last 6 months for grade 3 posterior vaginal prolapse, experiencing mild to moderate pelvic discomfort. Examination today shows similar findings with no progression or improvement. = Counsel for surgical management

0434. A 35-year-old pregnant patient at 29 weeks gestation notices a bulge protruding from the vagina. She denies any pain, discomfort, or urinary or gastrointestinal symptoms. Examination reveals grade 2 posterior vaginal prolapse. = Conservative management with reassurance

0435. An 80-year-old woman presents with urgency, frequency, and burning micturition for the past week. Examination reveals grade 2 anterior and vaginal prolapse. = Urine analysis

0436. A 20-year-old healthy woman, recently married, presents with a 1-week history of urgency and occasional urinary incontinence. Pelvic examination is unremarkable. = Urine analysis and culture

0437. A 20-year-old woman at 6 weeks gestation is receiving methotrexate treatment for an ectopic pregnancy. The first dose of methotrexate 50 mg/m² IM was administered one week ago. = Administer a second dose of methotrexate

0438. A 30-year-old woman at 6 weeks gestation is receiving methotrexate treatment for an ectopic pregnancy. The first dose of methotrexate 50 mg/m² IM was administered one week ago. = Repeat beta-hCG in 1 week

0439. A 30-year-old woman at 6 weeks gestation is receiving methotrexate treatment for an ectopic pregnancy. The first dose of methotrexate 50 mg/m² IM was administered one week ago. = Perform immediate surgical intervention

0440. A healthy 20-year-old woman at 6 weeks’ gestation with a diagnosis of ectopic pregnancy has received a first dose of methotrexate 50 mg/m² IM 14 days ago. = Repeat beta-hCG in 1 week

0441. The first dose of methotrexate 50 mg/m² was administered intramuscularly 14 days ago to a healthy 20-year-old woman at 6 weeks gestation with a diagnosis of ectopic pregnancy. = Perform a transvaginal ultrasound assessment

0442. A 35-year-old woman underwent an uneventful suction evacuation procedure for a suspected hydatidiform mole. The human chorionic gonadotropin (hCG) level prior to the procedure was taken (see lab result and report). Histopathology: Confirmed the diagnosis of hydatidiform mole. = Weekly beta-hCG until negative, then monthly for 6 months

0443. A 35-year-old woman underwent suction curettage for a molar pregnancy, and her beta- hCG level was 70,000 mIU/mL prior to the procedure. = Repeat beta-hCG in 1 week

0444. A 35-year-old woman presents with unusual vaginal bleeding and a fleshy vaginal mass. She underwent a suction evacuation for hydatidiform mole. Her beta-hCG level was 870,000 mIU/mL prior to the procedure. = Perform a metastatic workup without biopsy

0445. A 29-year-old woman presents to the clinic with 3-month postpartum abnormal vaginal bleeding. An examination reveals a fleshy vaginal mass protruding from the cervix that bleeds on touch (see report). Ultrasound: A mass protruding from the cervix, involving the uterine cavity. = Request metastatic workup

0446. A 34-year-old is inquiring about an effective reversible method of contraception. = Vaginal ring containing hormone

0447. A 20-year-old primigravida woman at 7 weeks’ gestation is diagnosed with a 4-cm stable right tubal ectopic pregnancy. She has no clinical symptoms. = Surgical excision of the ectopic

0448. A 32-year-old patient became pregnant through in-vitro fertilization. She is now 7 weeks pregnant and is scheduled for laparoscopic surgical excision of an ectopic pregnancy (see report). Ultrasound: Presence of a right-sided 4-cm ectopic pregnancy and a left tubal hydrosalpinx. = Excision of both right and left tubes

0449. A 33-year-old patient presents with vaginal spotting for the last 3 days. She is 7 weeks pregnant, and the transvaginal scan does not reveal an intrauterine or extrauterine gestational sac. = Repeat lab and ultrasound evaluation in 48 hours

0450. A 17-year-old primigravida presents to the clinic for the first time after missing her period, with a positive home pregnancy test. Her last menstrual period was 5 weeks ago. Pelvic examination reveals a closed cervical os with no bleeding (see report). Transvaginal Ultrasound: An intrauterine gestational sac with no embryonic heartbeat. = Intrauterine pregnancy of uncertain viability

0451. A 17-year-old primigravida presents to the clinic for the first time after missing her period, LMP 9 weeks ago, and with a positive home pregnancy test. Pelvic examination reveals a closed cervical os with no bleeding (see report). Transvaginal Ultrasound: An intrauterine gestational sac with a crown-rump length of 9 weeks’ gestation with no embryonic heartbeat. = Missed

0452. A 34-year-old woman presents at 10 weeks of gestation to the Emergency Department with fetal death, without expulsion of any fetal tissue for at least 8 weeks. = Missed

0453. An 18-year-old primigravida presents to the clinic for the first time after she missed her period, LMP 9 weeks ago, and with a positive home pregnancy test. Pelvic examination reveals an open cervical os with membranes protruding through the cervix (see report). Transvaginal Ultrasound: An intrauterine gestational sac with a crown-rump length of 9 weeks’ gestation with a positive embryonic heartbeat. = Inevitable miscarriage

0454. A 17-year-old primigravida presents to the Emergency Department complaining of vaginal bleeding and feeling unwell. She missed her period and has a positive home pregnancy test. Her last menstrual period was 9 weeks ago. Pelvic examination reveals an open cervical os with the gestational sac protruding through the cervix (see report). Transvaginal Ultrasound: An intrauterine gestational sac with a crown-rump length corresponding to 9 weeks’ gestation with a positive heartbeat. = Septic miscarriage

0455. A 17-year-old primigravida presents to the Emergency Department complaining of vaginal bleeding and abdominal cramping. She has a positive home pregnancy test, and her last menstrual period was 9 weeks ago. Pelvic examination reveals a closed cervix with bleeding noted through (see report). Transvaginal Ultrasound: Intrauterine gestational sac with a crown-rump length corresponding to 9 weeks’ gestation with a positive heartbeat. = Admit, stabilize, and prepare for possible termination of pregnancy

0456. A 17-year-old primigravida presents to the Emergency Department complaining of mild vaginal bleeding and abdominal cramping. Her last period was 9 weeks ago, and she has a positive home pregnancy test (see report). Transvaginal Ultrasonography: Intrauterine gestational sac with a crown-rump length corresponding to 9 weeks’ gestation with a positive heartbeat. = Pelvic assessment

0457. A 17-year-old primigravida presents to the Emergency Department complaining of mild vaginal bleeding and abdominal cramping. She missed her period along with a positive home pregnancy test, and her LMP was 6 weeks ago. Pelvic examination reveals an open cervical os with mild vaginal bleeding through the cervix. = Transvaginal ultrasound

0458. A 19-year-old primigravida presents to the Emergency Department complaining of abdominal cramps and mild vaginal bleeding. Her LMP was 6 weeks ago, with a positive home pregnancy test. Pelvic examination reveals a closed cervical os with abdominal pain on manipulation of the cervix. = Transvaginal assessment

0459. A 35-year-old woman presents to the Emergency Room with sudden severe abdominal pain for the last three hours, sharp and radiating to the right shoulder. She has an irregular menstrual cycle, and the last episode was six weeks ago (see report). Pelvic ultrasound: Abundant fluid collected in the pouch of Douglas. = Ruptured ectopic pregnancy

0460. A 35-year-old woman presents to the Emergency Room with sudden severe abdominal pain for the last three hours, sharp in nature and radiating to the right shoulder. She has an irregular menstrual cycle, and the last episode was six weeks ago. Examination reveals guarding and rigidity of the abdomen. = Pregnancy test

0461. A 30-year-old woman presented to the Emergency Room with sudden severe and sharp abdominal pain for the last three hours, radiating to the right shoulder. She has an irregular menstrual cycle, and the last episode was six weeks ago. Examination revealed a rigid abdomen with guarding of note (see report). Pelvic Ultrasound: Abundant fluid in the pouch of Douglas. = Laparotomy

0462. A 33-year-old woman presents to the Emergency Room with sudden severe abdominal pain for the last three hours, sharp in nature, and radiating to the right shoulder. She states that her cycles are irregular, and her LMP was six weeks ago. Examination reveals guarding and rigidity. = Laparotomy

0463. An 18-year-old woman presents to the Emergency Room with mild vaginal bleeding. Her last menstrual period was 9 weeks ago. Examination revealed the uterus is palpable, soft, and reaching to just above the symphysis pubis. = Pelvic ultrasound

0464. A pregnant patient presents with an ultrasound image resembling a snowstorm appearance. = Molar pregnancy

0465. A patient presents 3 weeks after vaginal delivery with sudden vaginal bleeding of 700 cc. = Late postpartum

0466. A patient presents 10 hours after vaginal delivery with sudden vaginal bleeding of 700 cc. = Early post-partum

0467. A patient presents at 32 weeks of gestation with sudden vaginal bleeding of 700 cc. = Ante-partum

0468. A patient at 32 weeks of gestation is 7 cm dilated, suddenly develops vaginal bleeding of 700 cc. = Intra-partum

0469. A 33-year-old woman P2+3 is seen in the Emergency Department at 12 weeks of gestation with vaginal bleeding and lower abdominal pain. Digital pelvic examination revealed the cervix is partially dilated without passage of any products of conception. = Inevitable

0470. A 25-year-old woman P1+1 presented at 13 weeks of gestation with vaginal bleeding. Abdominal examination revealed the uterus is palpable at the symphysis pubis with a positive fetal heart. Vaginal examination revealed a closed cervix. = Threatened

0471. A 25-year-old woman presented with abnormal uterine bleeding, underwent an endometrial biopsy (see report). Endometrial biopsy: Atypical complex hyperplasia. = Oral progesterone

0472. A 23-year-old woman presented at 10 weeks of gestation with a history of vaginal bleeding, cramp-like pain, and passage of some placental tissue through the cervix. = Incomplete

0473. A 22-year-old primigravida who is Rh-negative delivered an Rh-positive infant. She received routine prophylactic Rh immunoglobulin at 28 weeks of gestation. = 300 mg

0474. A 24-year-old woman is seen in the preconception clinic. She was diagnosed with generalized tonic-clonic epilepsy 2 years ago. She is poorly controlled. = Review medication

0475. A 31-year-old woman presents to the Emergency Department with severe abdominal pain, dizziness, and mild vaginal bleeding. Her last menstrual cycle was 7 weeks ago with a positive pregnancy test. Examination revealed a distended abdomen and severe tenderness with guarding (see report). Pelvic Ultrasound: Free fluid in the cul-de-sac, and no gestational sac is seen. = Ruptured ectopic pregnancy

0476. A 24-year-old sexually active woman presented to the Gynecology Clinic with vaginal discharge. A Pap smear showed abnormal results. = Colposcopy

0477. A 33-year-old woman is seen post-delivery with postpartum hemorrhage. She had a forceps delivery of a 3.7 kg baby. Examination revealed laceration of the cervix, vagina, and the perineal body. = Genital tract trauma

0478. A 51-year-old woman P6+2 presents with pelvic pressure, heaviness in the lower abdomen, and heavy menstrual bleeding. Bimanual pelvic examination revealed a firm, irregular, enlarged uterus is felt (see report). Pelvic Ultrasound: A large submucous fibroid 7×8 cm in size. = Hysterectomy

0479. A 23-year-old woman, a known case of idiopathic thrombocytopenic purpura, delivered at 39 weeks of gestation, and her delivery was complicated with postpartum hemorrhage. = Platelet concentrate infusion

0480. A 22-year-old woman presents to the booking clinic after performing a home pregnancy test, which was positive. She is not sure of her dates, as she has irregular menses. = Crown rump length on ultrasound

0481. A 27-year-old woman, primigravida at 31 weeks of gestation, presented to the Emergency Department with tonic-clonic convulsions for the first time. Examination revealed she is unconscious, with a soft abdomen, fundal height corresponding to gestational age, and a positive fetal heart. = Open and maintain airway

0482. A 41-year-old woman Para 4 presented to the Gynecology Clinic with post-coital bleeding for the past three months. Her cycle is irregular, and she is not taking any contraception. Examination revealed a soft abdomen with no palpable masses. = Pap smear

0483. A 32-year-old woman with twin pregnancy, presented at 38 weeks of gestation in active labor. Examination revealed twin A is in vertex presentation, and twin B is also in vertex presentation. Both fetal heart rates are normal. = Spontaneous vaginal delivery

0484. A 39-year-old woman, a known case of chronic hypertension, presented at 37 weeks of gestation to the antenatal clinic for follow-up. Examination revealed that the uterine fundal height lags more than 3 cm behind the gestational age. = Abdominal circumference

0485. A 20-year-old primigravida is seen in the Antenatal Clinic for follow-up. Clinical examination of uterine fundal height on 2 occasions revealed that there is an element of intrauterine growth restriction. = Serial ultrasound

0486. A 33-year-old woman, known case of intrauterine growth restriction, presented at 38 weeks of gestation to labor and delivery. Examination revealed the fetus is in vertex presentation, cervix is 4 cm dilated with a reactive fetal heart on CTG. = Spontaneous vaginal delivery

0487. A 31-year-old woman at 42 weeks of gestation with firm dates presented to the Antenatal Clinic. Examination revealed that the fetal head is well fixed in the pelvis, and the cervix is favorable. = Induction of labor

0488. A 29-year-old known cardiac patient receiving anticoagulants is seen in the clinic for contraceptive advice. = Progesterone pills

0489. A 37-year-old primigravida with uterine fibroid presented at 34 weeks of gestation with abdominal pain and fever. Examination revealed the cervix is closed, and no uterine contractions are felt. = Observation

0490. A 33-year-old pregnant woman at 36 weeks of gestation presented with vaginal itching, burning, and irritation. Examination revealed a thick discharge with the appearance of cottage cheese in the vagina. = Topical antifungal

0491. A 32-year-old woman presents to the Infertility Clinic for investigations. She has been married for the last 3 years and is complaining of dysmenorrhea and deep dyspareunia. Abdominal and pelvic examination revealed no pathology. = Laparoscopy and dye test

0492. A 23-year-old pregnant woman is seen at 9 weeks of gestation with moderate pelvic pain, which is dull in nature (see report). Ultrasound: Presence of an ovarian cyst of 4 cm in diameter. = Observation

0493. A 27-year-old woman delivered 2 weeks ago and presented with a painful, hard mass in the right breast. She received a 4-day course of antibiotics with no improvement. Examination revealed she is febrile, and a breast abscess is suspected. = Breast ultrasound and surgical review

0494. A 26-year-old woman with primary infertility is seen in the gynecology clinic for investigations. Her FSH, LH, and serum prolactin are normal. Pelvic Ultrasound is also reported as normal. = Progesterone day 21 of cycle

0495. A 38-year-old woman P4+0 presented to the clinic with mild stress urinary incontinence, which was proven by the cough stress test. = Pelvic floor muscle exercise

0496. A 42-year-old woman presented with pelvic pressure, bloating, and heaviness in the lower abdomen. Her cycle is prolonged with heavy menstrual bleeding (see report). Ultrasound: Presence of uterine fibroid. = Submucosal fibroid

0497. A 42-year-old P4+2 presented with severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrated a tender, diffusely enlarged uterus (see report). Endometrial biopsy: Normal endometrium. = Adenomyosis

0498. A newly married woman is presented to the gynecology clinic for a routine examination and checkup. = Pelvic digital examination

0499. A 25-year-old woman presents at 10 weeks of gestation for booking in the antenatal clinic. She gave a history of previous intrauterine death with multiple congenital anomalies. = 18-22 weeks

0500. A 27-year-old woman is seen during the active stage of labor at 39 weeks of gestation. CTG shows late decelerations of the fetal heart. = Change maternal position

0501. A 35-year-old woman known case of chronic hypertension presented at 22 weeks of gestation with a blood pressure of 140/90 mmHg. = Methyldopa

0502. A 26-year-old woman presents at 29 weeks of gestation with prelabor premature rupture of membranes for 7 days. Examination revealed she is having lower abdominal pain, rigors, and fever with purulent, foul-smelling vaginal discharge. = Chorioamnionitis

0503. A 31-year-old woman is seen in the Antenatal Clinic. She gave a history of a previous recurrent abortion in the first trimester of pregnancy. = Karyotyping

0504. A 33-year-old woman on oral contraceptive pills with strong androgenic progestin is seen in the clinic with a positive pregnancy test, where she is unaware of this pregnancy. = Masculinization

0505. A 32-year-old woman presented with reduced fetal movements at 36 weeks of gestation. = CTG

0506. A 23-year-old woman found to be hepatitis B surface antigen positive at 14 weeks of gestation. = Both hepatitis B vaccination and immunoglobulin

0507. A 33-year-old woman presented in preterm labor at 27 weeks of gestation. Examination revealed the cervix is 6 cm dilated. = Steroids

0508. A 23-year-old primigravida presented at 29 weeks of gestation with eclamptic seizures. = Magnesium sulfate

0509. A 39-year-old woman presented at 37 weeks of gestation with scanty vaginal bleeding. She is a known case of placenta previa totalis with a history of two previous episodes of vaginal bleeding. = Immediately

0510. A 27-year-old woman presented at 39 weeks of gestation with a history of spontaneous rupture of membranes 24 hours ago. Examination revealed a soft abdomen, cephalic presentation, and no uterine contractions. CTG shows normal fetal heart. = Induction of labor

0511. A 35-year-old woman with a history of three previous cesarean sections is admitted for elective surgery at 37 weeks of gestation. The placenta is found to be attached deeply into the uterus. = Placenta accreta

0512. A 26-year-old primigravida presented at 34 weeks of gestation with eclamptic seizures. The seizures were controlled, and her blood pressure was brought down by antihypertensive medications. = Arrange for delivery immediately

0513. A 27-year-old woman presented at 32 weeks of gestation with preterm labor. Her membrane was ruptured 12 hours ago, and she has been on antibiotics. She received the first dose of steroids. = Magnesium sulfate

0514. A 33-year-old woman, known case of low-lying placenta, presented at 35 weeks of gestation with mild vaginal bleeding at home. Examination revealed her vital signs are normal, and no more bleeding is noted. = CTG

0515. A 22-year-old primigravida is admitted for induction of labor at 41 weeks of gestation. Examination revealed the cervix is closed and long. = Prostaglandin E2

0516. A 35-year-old primigravida is seen in the Antenatal clinic for follow-up. She is currently smoking 12-15 cigarettes/day. She also gave a history of subfertility and a family history of diabetes in a second- degree relative. = Smoking

0517. A 33-year-old woman diagnosed with abruptio placentae presented with intrauterine fetal death. Examination revealed the cervix is found to be 5 cm dilated with mild uterine contractions. = Augmentation of labor

0518. A 20-year-old primigravida presented to the Emergency Department at 30 weeks of gestation, complaining of headache and blurred vision. = Labetalol

0519. A 34-year-old woman at 27 weeks of gestation presented with preterm labor. She is started on Beta mimetics (tocolytics). = Palpitations

0520. A 24-year-old woman, known smoker, presented at 31 weeks of gestation with painful vaginal bleeding and uterine contractions. Fetal heart on CTG shows late decelerations. = Abruptio placentae

0521. A 23-year-old primigravida presented at 31 weeks of gestation with preterm labor. Examination revealed, the uterus is contracting and the cervix is closed. = Magnesium sulfate

0522. A 36-year-old woman with a previous history of two cesarean sections presented at 30 weeks of gestation with painless vaginal bleeding. Examination revealed, the uterus is soft, and the fetal heart rate is normal. = Placenta previa

0523. A 20-year-old primigravida presented at 31 weeks of gestation with a headache and blurred vision. Urine examination by dipstick shows ++ proteinuria. = Preeclampsia

0524. A 34-year-old pregnant woman at 36 weeks of gestation presented with acute painful vaginal bleeding associated with uterine tenderness. = Abruption placentae

0525. A 29-year-old woman at 29 weeks of gestation presented with preterm labor. = Indomethacin

0526. A 32-year-old woman presented with preterm labor at 34 weeks of gestation. Examination revealed, Symphysis fundal height corresponds to 34 weeks, vertex presentation. Vaginal assessment revealed that the cervix is 6 cm dilated. CTG confirms normal fetal heart. = Vaginal delivery

0527. A 30-year-old woman presented to the maternity unit at 30 weeks of gestation with massive antepartum hemorrhage. CTG is showing fetal distress. = Cesarean section

0528. A 30-year-old woman attends at 27 weeks of gestation with scanty vaginal bleeding. An ultrasound confirms placenta previa totalis. She is hemodynamically stable, and CTG is normal. = Steroids

0529. A 36-year-old woman has a normal vaginal delivery of a 4.2 kg baby. Post-delivery, she had a perineal laceration involving the rectal mucosa. = Fourth

0530. A 41-year-old woman is seen at 34 weeks of gestation in the antenatal clinic with an ultrasound report confirming excessive amniotic fluid. = Uncontrolled diabetes mellitus

0531. A 39-year-old woman presented at 14 weeks of gestation to the antenatal clinic for booking. She is a known case of hypertension and diabetes. = Review her medication

0532. A 65-year-old woman presented to the Emergency Room with a history of acute abdominal pain that increased markedly in the last few hours (see report). A solitary, cystic, right complex adnexal mass was observed. = Pelvic MRI

0533. A 20-year-old asymptomatic woman presented to the clinic with lower abdominal pain for 3 months (see lab result and report). Ultrasound: A multiloculated, solid, right adnexal complex mass of 6 cm. = Cystectomy

0534. A 76-year-old woman presented to the Emergency Room with a 1-week history of abdominal pain (see lab result and report). Ultrasound: A multiloculated, solid, right adnexal complex mass of 6 cm. = Consult gynecology oncology service

0535. A 21-year-old primigravida at 40 weeks of gestation with breech presentation is planned for a cesarean section. During surgery, a right ovarian cyst measuring 5 cm is observed. = Cystectomy

0536. A 20-year-old asymptomatic woman presented to the clinic with an incidental ultrasound finding that showed a simple right adnexal mass of 5 cm in size. = Reassess in 6 to 8 weeks

0537. A 60-year-old woman presented with weight loss and loss of appetite (see report). Ultrasound: Multiloculated, solid, right adnexal mass. = CA-125

0538. A 33-year-old woman presents at 9 weeks of gestation with mild vaginal bleeding. Examination of her abdomen reveals mild tenderness without rigidity or rebound tenderness. Pelvic examination reveals a closed cervix (see lab result and report). Ultrasound: Does not reveal any intrauterine or extrauterine pregnancy. = Methotrexate injection

0539. A 35-year-old patient, 16 days post-cesarean section, presents with a fever that is not responding to antipyretics and antibiotics. She had four previous cesareans, and during surgery, extensive adhesions were found. She is passing urine, flatus, and stool. Examination reveals abdominal tenderness (see report). Contrast CT scan confirms the diagnosis of a small bowel fistula. = NPO and start pancreatic and gastric secretion inhibitors

0540. A 30-year-old woman with primary infertility for the last 3 years is seen for follow-up in the clinic. Her investigations included a hormonal profile, and an ultrasound is normal. Her husband’s semen analysis is also normal. She had a 3-month trial of induction of ovulation with clomiphene. = Diagnostic laparoscopy

0541. A 21-year-old woman with primary infertility for the last 4 years is seen in the clinic for follow-up. Investigation showed that her hormonal profile is normal and her husband’s semen analysis is also normal. The hysterosalpingogram showed proximal blocked tubes bilaterally. = Diagnostic laparoscopy and dye test

0542. A 26-year-old woman with primary infertility for the last 4 years presents for follow-up in the clinic. The investigations showed a normal hormonal profile, and her husband’s semen analysis was also normal. She underwent hysterosalpingography and diagnostic laparoscopy and dye test, which confirmed the presence of bilateral tubal blockage. = In-vitro fertilization

0543. A 26-year-old woman has primary infertility for the last 4 years. Her investigations revealed a normal hormonal profile and her husband’s semen analysis is also normal. She underwent hysterosalpingography and diagnostic laparoscopy and dye test that confirmed the presence of a right fallopian tube blockage but the left tube was found to be patent. = Clomiphene citrate

0544. A 30-year-old G5P4 woman presents in labor at 34 weeks of gestation. Examination revealed the cervix was found to be 4 cm dilated and the vertex is at -3 station with intact membranes. Cardiotocography shows that the baseline is 110 beats per minute, accelerations were present, good variability with variable decelerations. The uterine contractions are strong and regular, occurring at a rate of 4 in 10 minutes. = Rupture the membranes

0545. A 35-year-old G8P7 woman presents in labor at 37 weeks of gestation. Examination revealed the cervix was found to be 10 cm dilated and the vertex is at -3 station. She suddenly complains of severe abdominal pain and vaginal bleeding. Cardiotocography shows that the baseline is 80 beats per minute, poor variability with recurrent late decelerations. Uterine contractions suddenly stopped being recorded on the CTG trace. = Immediate laparotomy

0546. A 30-year-old G5P4 woman presents in labor at 39 weeks of gestation. Examination revealed the cervix is found to be 7 cm dilated and the vertex is at -3 station. Cardiotocography shows that the baseline is 120 beats per minute, accelerations were present, good variability and occasional variable decelerations. The uterine contractions are mild and irregular, occurring at a rate of 2 contractions in each 10 minutes. = Augmentation of labor with oxytocin

0547. A 30-year-old G5P4 woman presents in labor at 37 weeks of gestation. Examination revealed the cervix is found to be 10 cm dilated and the vertex is at -3 station. Cardiotocography shows that the baseline is 90 beats per minute, accelerations were present, good variability with recurrent late decelerations present. The uterine contractions are regular and strong, occurring at a rate of 4 in 10 minutes. = Emergency cesarean section

0548. A 28-year-old primigravida presents in labor at 37 weeks of gestation. Examination revealed the cervix is found to be 10 cm dilated and the head is at +3 station. Cardiotocography shows that the baseline is 120 beats per minute, accelerations were present, good variability, and a prolonged deceleration was noted for the last 7 minutes. The uterine contractions are regular and strong. = Instrumental delivery

0549. A 20-year-old G2P1 presents in labor at 38 weeks of gestation. Examination revealed the cervix is found to be 4 cm dilated. Cardiotocography shows that the baseline is 140 beats per minute with a sinusoidal pattern observed in the last 40 minutes. The uterine contractions are regular and strong, occurring at a rate of 3 to 4 in 10 minutes. = Cesarean section

0550. A 24-year-old primigravida at 39 weeks of gestation is in the latent phase of labor. Examination revealed the cervix is 2 cm dilated. Cardiotocography shows a baseline of 140 beats per minute, moderate variability, no decelerations, and no accelerations present. Uterine contractions are mild and irregular. = Augmentation of labor

0551. A 40-year-old G8P7 woman presents in active labor at 40 weeks of gestation. Examination revealed the cervix was found to be 7 cm dilated. Cardiotocography shows a baseline of 120 beats per minute, no decelerations, and poor variability with recurrent variable decelerations. The uterine contractions are regular and strong, occurring at a rate of 4 in 10 minutes. = Emergency Cesarean section

0552. A 38-year-old woman is scheduled to undergo a myomectomy due to the presence of a large uterine fibroid. The surgeon is planning to administer medication that will help reduce the size of the uterine fibroid prior to performing the procedure. = GnRH injection

0553. A 38-year-old woman presents with pelvic pressure and menorrhagia. She was diagnosed to have a large uterine anterior wall fibroid of 10 cm in size. Ultrasound shows a distorted endometrial lining secondary to the fibroid. The patient was offered hysterectomy but she declined. = Uterine artery embolization

0554. A 24-year-old woman presents to the clinic with an incidental finding of a uterine fibroid. Her menstrual cycle is regular, and her examination is unremarkable. Ultrasound: An anterior subserosal fibroid of 3 x 2 cm, otherwise the other areas of the uterus, ovaries, and adnexa are unremarkable. = Reassure and follow-up

0555. A 32-year-old single woman is attending the clinic complaining of menorrhagia for the last few months. The physical examination is unremarkable. Pelvic Ultrasound: Presence of a serosal fibroid, 4 x 4 cm in size. Otherwise, the other parameters of the ultrasound were normal. = Non-steroidal anti-inflammatory drugs

0556. A 50-year-old woman presents with menorrhagia for the last year. The physical examination is unremarkable. A trial of medical treatment failed to control the bleeding for the last few months. Ultrasound: Presence of a fibroid, 7 x 7 cm in size, which is distorting the endometrial lining. = Hysterectomy

0557. A 25-year-old woman has been seeking fertility for the last 3 years. She had 2 unsuccessful in vitro fertilization trials. Pelvic Ultrasound: Multiple uterine fibroids of variable sizes. = Myomectomy

0558. A 60-year-old woman is attending the clinic complaining of post-menopausal bleeding for the last 3 months. She was found to have a uterine fibroid of 5 cm in size, noted in a recent ultrasound. Upon review of the previous medical records, the ultrasound performed 5 years ago showed the same size and location of the fibroid. = Obtain an endometrial sample

0559. A 25-year-old G2P1 woman at 39 weeks of gestation presents in the active phase of labor. Cardiotocography shows fetal tachycardia with a baseline of 180 beats per minute, with accelerations, early deceleration, and good variability. = Fetal tachycardia

0560. A 30-year-old G3P2 woman presents with mild abdominal pain at 34 weeks of gestation. Cardiotocography shows a baseline of 140 beats per minute, good variability, accelerations were present with no decelerations. The examination is unremarkable, and the cervix was found to be 1 cm dilated and uneffaced. = Reassurance

0561. A 38-year-old G4P3 woman at 35 weeks of gestation is being observed in the labor and delivery room as she is complaining of decreased fetal movement. Cardiotocography shows a baseline of 130 beats per minute, accelerations were seen, no apparent deceleration with poor variability. After one hour of observation with intravenous hydration and continuous CTG monitoring, CTG improved with good variability. = Discharge home with fetal kick chart

0562. A 23-year-old primigravida presents to the Emergency Room at 35 weeks of gestation complaining of decreased fetal movement for the last few hours. Examination revealed the cervix is 1 cm dilated and the head is at -2 station. Cardiotocography shows that the baseline is 160 beats per minute with good accelerations, good variability, and early decelerations. The uterine contractions are mild and regular. = Observation and continuous CTG monitoring

0563. A 23-year-old primigravida presents with mild, infrequent abdominal pains at 36 weeks of gestation. Cardiotocography shows that the baseline is 140 beats per minute with good accelerations and variability and no decelerations. The uterine contractions are irregular and mild. The examination is unremarkable with no cervical dilation. = Reassurance

0564. A 27-year-old G4P3 woman is seen in labor at 39 weeks of gestation. Examination revealed the cervix is 5 cm dilated with clear amniotic fluid draining. Cardiotocography shows that the baseline is 140 beats per minute, no accelerations, good variability, and no decelerations. The uterine contractions are regular and strong, occurring at a rate of 3 to 4 in 10 minutes. = Reassurance and reassessment in 30 to 60 minutes

0565. A 32-year-old G2P1 woman at 41 weeks of gestation presents in labor. Examination revealed the cervix is 7 cm dilated with meconium-stained amniotic fluid draining, and the head is at -2 station. Cardiotocography shows that the baseline is 100 beats per minute, with poor variability, no accelerations, and no decelerations. The uterine contractions are regular and strong, occurring at a rate of 3 to 4 in 10 minutes. = Emergency Cesarean section

0566. A 19-year-old primigravida is diagnosed with intrauterine growth restriction in the antenatal follow-up. She came in labor at 38 weeks of gestation, the cervix is found to be 4 cm dilated with meconium-stained amniotic fluid. The cardiotocography shows that the baseline is 130 beats per minute, with no accelerations, poor variability, and recurrent late decelerations. The uterine contractions are regular and strong, occurring at a rate of 3 to 4 in 10 minutes. = Emergency Cesarean section

0567. A 32-year-old woman G3P2 at 41 weeks of gestation is seen in the outpatient clinic. Abdominal palpation revealed there are no uterine contractions. Pelvic examination revealed that the cervix is thick and not dilated. The cardiotocography shows that the baseline is 130 beats per minute, with accelerations, good variability, and no decelerations. = Induction of labor

0568. A 28-year-old woman G3P2 at 38 weeks of gestation is in active labor. Examination revealed the cervix is found to be 6 cm dilated. The cardiotocography is showing that the baseline is 120 beats per minute, absent accelerations and variability with recurrent late decelerations. Uterine contractions are strong, occurring at a rate of 3 to 4 every minute. = Emergency cesarean section

0569. A 23-year-old patient at 38 weeks of gestation is in active labor and diagnosed with cord prolapse. = Variable decelerations and bradycardia

0570. A 30-year-old woman delivered a 4.2 kg baby without an episiotomy being required. The placenta was completely delivered by continuous cord traction. Post-delivery, the patient started to have a sudden gush of heavy vaginal bleeding. = Check uterine contractility

0571. A 33-year-old G3P2 woman presents with mild uterine contractions for 12 hours. Examination revealed fundal height corresponds to gestational age, cephalic presentation, and mild contractions. Pelvic assessment shows the cervix is 4 cm dilated, and the head is at -1 station. = Augmentation of labor

0572. A 21-year-old healthy primigravida is at 40 weeks in active labor. Pelvic assessment reveals that the cervix is 7 cm dilated, draining clear amniotic fluid, and the head is at +1 station. She is contracting regularly, 3 contractions in every 10 minutes, and the CTG is showing decelerations. = Early decelerations

0573. A 30-year-old woman G3P2 is at 37 weeks of gestation. She is a case of Rh isoimmunization and the fetus is diagnosed with fetal anemia. = Immediate delivery

0574. A 35-year-old woman, G3P2 diabetic patient at 38 weeks of gestation, is planned to have induction of labor. She has no abdominal or pelvic pain, and no vaginal loss. Examination revealed the uterine size corresponds to gestational age, soft, and not tender. Pelvic examination shows the cervix is closed and uneffaced. CTG is done. = Reassuring pattern

0575. A 33-year-old woman G5P4 with a history of 4 previous cesarean sections presents at 37 weeks of gestation to the Emergency Room complaining of contractions that started 8 hours ago. The pain progressed to become severe with moderate vaginal bleeding, and low blood pressure. She became restless and hyperventilated. = Uterine rupture

0576. A 25-year-old woman is seeking fertility assistance and had undergone investigations that revealed that ovulation is regular and her husband’s semen analysis is adequate. = Fallopian tubal patency

0577. A 26-year-old woman presents with amenorrhea for the last 14 weeks. She started to have mild vaginal bleeding for the last 3 days. Examination revealed the uterine size is 18 weeks and is doughy on palpation. Ultrasound: An enlarged uterus with a snowstorm appearance. = Surgical suction and evacuation procedure

0578. A 25-year-old woman is seen in the infertility clinic as a case of primary infertility for 2 years. Her history revealed that she has had amenorrhea for the last 6 months and only gets menstruation through using withdrawal bleeding pills. She had investigations repeated twice, performed 3 months apart, and they were all showing the same results. = Hormone replacement therapy

0579. A 40-year-old woman presents with menorrhagia for the last 6 months. She underwent an endometrial biopsy. Endometrial biopsy: Presence of simple endometrial hyperplasia without atypia. = Progesterone therapy

0580. A 50-year-old woman presented to the clinic with prolonged and heavy menstruation for the last 8 months. She underwent an endometrial biopsy. Endometrial biopsy: Presence of endometrial hyperplasia with atypia. = Hysterectomy

0581. A 70-year-old woman presented with post-menopausal bleeding for the last 7 months. Endometrial biopsy: Endometrial hyperplasia with atypia. She is unfit for surgery and anesthesia. = Continuous progesterone treatment

0582. A 24-year-old woman is admitted to the labor and delivery unit at 37 weeks of gestation in labor. She is pregnant with monochorionic monoamniotic twins, and the first twin is in breech presentation while the second is in cephalic presentation. Examination revealed the cervix is 4 cm dilated. = Cesarean section

0583. A 24-year-old woman has been trying to get pregnant for the last 18 months. She was recently diagnosed with polycystic ovarian syndrome and has irregular menstrual cycles. Her husband’s semen analysis was normal, and she has not received any medication. = Induction of ovulation using clomiphene

0584. A 30-year-old woman at 36 weeks of gestation presents with painless vaginal bleeding for one day. = Ultrasound

0585. A 50-year-old woman had a recent miscarriage and is inquiring if her age contributed to the miscarriage. = Risk is between 10% to 50%

0586. A 23-year-old woman presents at 18 weeks of gestation with a sudden unexpected rupture of membranes followed by painless expulsion of products of conception. = Cervical incompetence

0587. A 25-year-old woman in her mid-trimester of pregnancy presents with a sudden unexpected rupture of membranes followed by painless expulsion of the products of conception. = Cervical incompetence

0588. A 45-year-old otherwise healthy woman presents to the clinic complaining of amenorrhea for the last 18 weeks. Her periods prior to this were all regular. Ultrasound: Presence of a snowstorm pattern within the uterine cavity. = Human chorionic gonadotropin level

0589. A 26-year-old woman was treated with methotrexate for an ectopic pregnancy. = ****

0591. A 26-year-old woman was treated with methotrexate 8 days ago for ectopic pregnancy and presents to the Emergency Room with mild abdominal pain and vaginal spotting. Examination revealed a soft and non-tender abdomen. Her BhCG results show a drop from 1200 miu/ml on Day 4 to 500 miu/ml on Day 7. = Reassure and follow up

0592. A 35-year-old woman presents with severe generalized abdominal pain, associated with nausea and vomiting for the last few hours. She is known to have an intrauterine contraceptive device inserted for the last 3 years. She did a home pregnancy test, which was positive. Ultrasound: Fluid collection of approximately 13 x 15 cm. No identified gestational sac. Both ovaries are normal. = Ruptured ectopic pregnancy

0593. A 25-year-old woman was diagnosed to have a complete abortion at 10 weeks of gestation. The patient is a heavy smoker and smokes more than 20 cigarettes a day. She was not taking any folic acid or dietary supplements. = Smoking more than 20 cigarettes a day

0594. A 50-year-old otherwise healthy woman presents to the Emergency Room with a history of amenorrhea for the last 17 weeks. Examination revealed normal vital signs. The uterine size corresponds to 20 weeks of gestation and feels doughy. = Ultrasound

0595. A 17-year-old patient presents with a period of amenorrhea for the last 18 weeks. The uterus is about 22 weeks in size and feels doughy and compressible. Ultrasound: A snowstorm appearance with no clearly identified fetal pole. = Complete mole

0596. A 45-year-old woman presents with menorrhagia for the last 8 months. She is known to be diabetic and hypertensive. Ultrasound: Thickened endometrial lining of approximately 23 mm. = Endometrial biopsy

0597. A 22-year-old, otherwise healthy woman, presents to the Emergency Room complaining of amenorrhea for the last 8 weeks and expelling blood and tissue through the vagina. = Pelvic examination and ultrasound scan

0598. A 30-year-old, 12 weeks pregnant woman presented to the Emergency Room with vaginal bleeding. Examination revealed her fundal height corresponded with 19 weeks of gestation. = Complete mole

0599. An 18-year-old patient presents with amenorrhea for the last 15 weeks. She complains of vaginal bleeding and passage of tissue that she describes as vesicles. Ultrasound: A grape-like structure is filling the uterine cavity completely. = Complete Mole

0600. A 44-year-old woman was just recently diagnosed with partial molar pregnancy, which was confirmed by histopathology. = Weekly BhCG blood test