A 50-year-old woman presents with chest discomfort for 2 days. It lasted for 3 hours on the first day and 6 hours the second. Onset was while she was playing cards. She describes it as indigestion. She walks 2 miles a day, and has never smoked. She has a family history of atherosclerosis in her father. Her BMI is 25, blood pressure is 124/74, and heart rate is 72. HDL is 55, LDL is 78, TG 120, and total cholesterol is 188. She is in mild discomfort as you examine her. Her EKG during the discomfort shows 3 mm ST elevation. Troponin I rises to 4.2 µg/L (normal < 0.04). Her treadmill stress test shows mild apical T-wave inversion. Her cardiac catheterization shows no luminal defects.
How do you counsel her for future treatment?
This patient’s laboratory and testing prove she has suffered a myocardial infarction. Women with coronary disease commonly present with vague symptoms, such as shortness of breath, nausea, vomiting, indigestion, fatigue, or upper back pain, as compared with the classic symptoms of chest pain, tightness, or pain radiating to the arms or jaw. Cardiologists recognize that the etiology of women’s ischemia is commonly due to small-vessel vasospasm, not the classic lumen narrowing with plaque that is easily seen on catheterization. Therefore, prevention of further vasospasm with vasodilators, such as nitroglycerin preparations or long-acting calcium-channel blockers (CCB), may provide additional benefit to established secondary prevention treatments, such as statins and aspirin. Secondary prevention according to the American Heart Association guidelines recommend a goal LDL of less than 70, triglycerides less than 150, and HDL greater than 50. Warfarin is not indicated for secondary prevention of myocardial infarction. Treatment of noncardiac chest pain can include proton pump inhibitor trials or benzodiazepines for anxiety or panic disorder. This patient, however, clearly has ischemic heart disease, and treatment should be directed to preventing future cardiac events.
A 25-year-old woman presents to your office with complaints of pain during intercourse for 2 months. The pain occurs with initial penetration and continues throughout the entire episode. She relates that she and her husband have been married for a year and previously had a pleasurable, pain-free relationship. She tells you that shehas been to several area doctors, and had a “full workup” without a diagnosis, including a pelvic examination, pap smear with cultures, and sonogram. When you examine her, she has a normal pelvic examination with no pain. You are unsure of the differential diagnosis, so you continue taking more history. She admits to vaginal dryness and low libido during this same timeframe. You ask if anything in her life changed 2 months ago. She suddenly begins to cry and states she found evidence of her husband’s infidelity 2 months ago.
What is the most appropriate recommendation for your patient?
An organic cause of this patient’s sexual dysfunction is unlikely. Her pain during intercourse, poor desire, and lack of sufficient lubrication probably stem from the psychological stress from her husband’s infidelity. Marital counseling may aid in resolving the issues that resulted in the infidelity, and the aftermath. Female sexual dysfunction consists of four broad categories: dyspareunia, orgasmic disorder, arousal disorder, and impaired sexual drive. Sexual dysfunction results from physical conditions, such as neuropathy or sleep deprivation, or from psychological conditions, such as depression or a history of abuse. A thorough evaluation should include medical conditions as well as psychosocial questions pertaining to the health of her relationship with her partner and personal issues that contribute to her sexual well-being. The other answers are effective treatments for specific types of sexual dysfunctions; however, they will not address the cause of this woman’s distress.
A 65-year-old woman presents for her annual examination. She has been feeling well and has no complaints, except for vaginal itching. She used antibiotics about 4 months ago for a sinus infection, but reports no other medications. She denies vaginal discharge. On examination, you see that the labia minora have regressed, the clitoral hood is fused, and the skins of the labia majora, perineum, and anus are smooth and whitish. After treating her with topical steroid ointment for 6 weeks, examination reveals an area of the labia which failed to return to pink.
What is your best next choice in management?
Lichen sclerosus is a common chronic atrophic mucocutaneous disorder that may be asymptomatic or may cause vulvar pruritus, dysuria, or dyspareunia. The sharply demarcated white plaques typically appear in a keyhole or figure-of-eight arrangement involving the clitoral hood, labia minora, perineum, and anal area. The labia minora may appear reabsorbed, termed agglutination. The cause is unknown. Topical steroids promote remission. As lichen sclerosus can cause scarring, this skin is more likely to evolve into squamous cell carcinoma, Any lesion which does not resolve with steroid treatment should be biopsied. Topical antifungals and antibiotics have a role in chronic infections causing vulvodynia, but are not indicated in lichen sclerosus. Vulvar psoriasis may be difficult to distinguish from lichen sclerosus, but before empiric therapy is given, biopsy is needed to rule out the presence of vulvar cancer and to establish a definitive diagnosis. Subcutaneous steroid injections may be an option if the biopsy just shows persistent lichen sclerosus.
A 33-year-old woman presents to your office with complaints of inability to become pregnant. She and her husband have been having regular intercourse for 10 years without contraception. Her husband has normal sperm count and motility. Her menses are irregular, occurring every 28 to 60 days. She has noticed some facial and upper back acne, as well as increased amount of pubic hair. On examination, her waist circumference is 36 in and she has cystic acne on her neck, forehead, and upper back. She also has acanthosis nigricans in her groin and posterior neck.
What is the best plan for the initial management of this patient?
This woman has polycystic ovarian syndrome (PCOS), the most common cause of infertility in women. Although the precise definition of PCOS is controversial, most agree it may be diagnosed in women with some combination of oligomenorrhea, clinical, or biochemical evidence of hyperandrogenism (excluding other causes of hyperandrogenemia), and polycystic ovaries by ultrasound. (Polycystic ovaries on ultrasound are not required in the diagnosis of PCOS.) High levels of androgens, either from the ovaries or the adrenal glands, interfere with ovulation and result in ovarian cyst formation, excess facial and body hair, and acne. Most women with PCOS will have elevated serum DHEA-S and testosterone concentrations. Hyperinsulinemia and insulin resistance, seen clinically as acanthosis nigricans, are also common findings. Women with PCOS are at increased risk of metabolic syndrome, diabetes, and cardiovascular disease. Exercise and weight loss are firstline recommendations, and may restore normal ovulation without medications. Treatment for women not pursuing pregnancy includes oral contraceptives or metformin. Spironolactone has clinical efficacy but is not FDA approved for this use. Rapid weight loss through gastric bypass is not the best option for this patient due to her mild obesity and her desire to become pregnant immediately. Isotretinoin for acne treatment should not be used in women actively trying to conceive due to the extremely high risk of birth defect.
A 28-year-old woman complains of fatigue and a sense of fullness at the base of her neck. She has no significant past medical history, gave birth to a healthy infant 4 months ago, and is only taking oral contraceptives. On examination, vital signs show pulse 88, blood pressure 110/66, temperature 37°C (98.6°F), and respirations 12. Her thyroid gland is homogeneously enlarged, and she has a very mild tremor of the outstretched hands. The rest of the examination is normal. Laboratory evaluation reveals the following:
What is the most likely diagnosis?
The patient’s clinical presentation is most consistent with postpartum thyroiditis, a form of autoimmune-induced thyrotoxicosis that occurs 3 to 6 months after delivery. The hyperthyroid state usually lasts for 1 to 3 months and is generally followed by a hypothyroid state of limited duration. The patient’s thyroid gland would not be enlarged if she were taking exogenous thyroid medications. Subacute thyroiditis usually presents with a tender, enlarged thyroid gland. The patient’s thyroid gland is described as homogeneous, not nodular, which would be inconsistent with toxic multinodular goiter. Struma ovarii is unlikely because of the enlargement of the thyroid gland. Struma ovarii is the name given to the approximately 3% of ovarian dermoid tumors or teratomas that contain thyroid tissue. This tissue may autonomously secrete thyroid hormone. Postpartum thyroiditis can be distinguished from Graves disease with thyroid uptake scan; uptake will be suppressed in thyroiditis but normal to increased in Graves disease.
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