Clinical chapters 13,14,15,16,17

A 28y.o woman presents to the emergency department with increasing abdominal and pelvic pain. the patient states that she has been treated twice within the last year for PID, but she has not felt like this during the previous episodes. she thinks she may have a pelvic infection again, but she is also having pain in her RUQ that is more severe when she coughs or moves. sonography of the gallbladder appears normal. whats the dx?

Fitz-hugh-curtis syndrome

A 35y.o woman with pelvic pain undergoes a pelvic sonogram. she has had an IUD for the past 3 years without complication. the sonogram reveals a normal-appearing uterus with an IUD located in the lower uterine segment. this is consistent with which of the following.

IUD migration

A 40y.o woman goes presents for a pelvic sonogram because of abnormal menses. the sonogram reveals a copper 7 IUD, which has been in place for 12 years. what is the most likely course of treatment for this patient?

IUD removal because copper IUDs lose effectiveness after 10 years

a 23y.o woman undergoes a pelvic sonogram for missing IUD strings. her last menstrual cycle was 6 months prior, and a recent pregnancy test was negative. an IUD with a hypoechoic stem and hyperechoic arms is identified in the endometrial cavity. based on the patients history and sonographic findings, what type of IUD is imaged?

Mirena

A 22y.o woman with irregular menses presents for a transvaginal sonogram. the right ovary contains 15 follicles in the periphery measuring 3 to 6mm in diameter. the left ovary and the uterus appear normal. the sonographic findings are compatible with?

PCOS

A 26y.o woman has abnormal hair growth on her chin and elevated serum testosterone levels. her last menses were two years ago. her urine pregnancy test was negative. on transvaginal sonography, both ovaries are enlarged, measuring greater than 15mL in volume. what is the most likely cause for her symptoms?

PCOS

A 31y.o woman with irregular menses and infertility presents for pelvic sonography. the ovaries have eight follicles measruing 3 to 6mm in diameter. the most likely reason for this finding is?

PCOS

A 28y.o woman is seen in the ER for pelvic pain that has increased over the last 4 to 5 days. she states that she had an IUD placed by a physician in a clinic approximately 2 weeks ago and has had "problems" since then. while obtaining the patients hx, the patient says shes had PID in the past but has not had any problems lately. on pelvic exam, the patient experiences severe pain with any movement of the cervix. lab work shows an elevated WBC and elevated ESR. whats the dx?

PID from an IUD placement

An 18y.o female college student presents to the ER with pelvic pain. initial lab work shows an elevated WBC count, elevated ESR, negative HCG, and normal urinalysis. during a pelvic exam, the patient experiences severe pain with any manipulation of the cervix. sonography of the pelvis was ordered for suspected PID. on transabdominal sonogram the uterus and ovaries appear normal with no free fluid seen. the patient refused endovaginal sonography because of the pain. what is the likely dx?

PID is still likely, even with a normal transabdominal sonogram

A 30y.o woman 2 months postpartum with AUB undergoes transvaginal sonography. the exam reveals a normal sized uterus, a 12cm thick endometrium, and an echogenic mass within the uterine cavity. HCG testing is negative. what is the most likely cause of AUB?

RPOC

A patient who is scheduled for a pelvic sonogram state that she currently has a mirena IUD in place. what is the shape of the IUD?

T-shaped

A patient presents with a history of severe pelvic pain, fever, and purulent discharge. a pelvic sonogram demonstrates a properly placed IUD and a complex adnexal mass. the ovary cannot be identified within or adjacent to the adnexal mass. what is the most likely dx?

Tuboovarian abscess

A mother brings her 15y.o daughter to her pediatricians office for increasing pelvic pain over the last few days. the mother is concerned that the daughter may have an ovarian cyst. while obtaining the patients hx, the patient seems hesitant to answer the questions and seems elusive but does state that she had her appendix removed when she was 110y.o. after the pediatrician asks the mother to leave the room for a few minutes, the daughter states that she is sexually active with a guy she met online a few months ago. a urine test is negative for pregnancy, but the patients temp. is 100.7F. whats the dx?

acute PID(pelvic inflammatory disease)

A 26y.o white woman presents to the ER with acute LLQ and flank pain. the patient reports that the pain was better when she laid still and worse with movement or sitting. she claims no sexual activity in the last few months. initial lab work shows a WBC of 20,550/uL with a shift to the left, and urinalysis is negative for RBC. a CT no shows no evidence of kidney stones but reveals bilateral cystic masses in the pelvis. sonography shows a 4cm right ovarian cyst and a left adnexal tubular structure with internal echoes and hyperemia. whats the dx?

acute left pyosalpinx

A 50y.o woman experiencing AUB undergoes pelvic sonography. the uterine body is globular and slightly heterogenous in appearance, several myometrial cysts are identified, and the endometrial-myometrial junction is not clearly delineated. what is the most likely dx?

adenomyosis

1a 27y.o woman with recurrent miscarriages presents for a pelvic sonogram. sonography reveals a subtle fundal indentation on the uterus with a slightly concave uterine cavity. these findings are associated with which uterine anomaly?

arcuate uterus

A 75y.o woman undergoes a pelvic sonogram because of increasing abdominal girth and complaints of feeling exhausted. sonographic evaluation demonstrates a 20cm, complex predominantly cystic mass occupying her pelvis and abdomen. multiple papillary projections and septations are evident within the mass, which demonstrate vascularity on color doppler imaging. whats the dx?

cystadenocarcinoma

A 19y.o woman was referred for a pelvic sonogram because of a palpable right adnexal mass and no other symptoms. the sonographer was unable to identify a normal right ovary but noticed a discrete area with hyperechoic dots and lines, including a rounded echogenic area that produced a shadow. at first, the area was thought to be bowel, but on observation there was no peristalsis. these findings are most consistent with which type of ovarian mass?

cystic teratoma

A patient with a positive serum pregnancy test and an IUD in place is seen for sonographic exam. the sonogram reveals an IUD within the uterine cavity with no evidence of an intrauterine gestation. a complex adnexal mass separate from the ovary is identified, and a moderate amount of hypoechoic fluid is noted in the cul-de-sac and right upper quadrant. the patients last menstrual cycle was 7 weeks prior. what is the most likely dx for this patient?

ectopic pregnancy

A 25y.o woman with menorrhagia undergoes a pelvic sonogram, which demonstrates multiple intramural and subserosal fibroids, with the largest measuring 8cm. the physician presents several treatment options. the patient wishes to maintain fertility. which of the following is not a treatment option most likely to be offered?

endometrial ablation

A 75y.o woman with postmenopausal bleeding undergoes pelvic sonography, which reveals a 1.5cm endometrium. what is the most likely dx?

endometrial carcinoma

A 48y.o woman undergoes a pelvic sonogram because of AUB. the uterus has a homogenous echotexture, and endometrial thickness is 1.7cm. sonohysterography reveals diffuse endometrial thickening with no intraluminal masses. What is the dx?

endometrial hyperplasia

A 45y.o woman with intermenstrual spotting undergoes transvaginal sonography. endometrial thickness is 20mm, and saline introduced during hysterosonography outlines a focal mass isoechoic to the endometrium. what is the most likely dx?

endometrial polyp

A 50y.o woman with AUB undergoes a pelvic sonogram. Transvaginal sonography reveals a thickened endometrium with a single vascular feeding vessel apparent on color doppler imaging. What is the most likely dx?

endometrial polyp

A 28y.o woman with dysmenorrhea since age 14 comes in for a pelvic sonogram. a right ovarian cyst is seen with thick walls and a fluid/debris level. this same mass was seen sonographically 3 months ago. it is tender on imaging with the vaginal probe. whats the dx?

endometrioma

A 30y.o woman with pelvic pain and dyspareunia presents for a pelvic ultrasound. sonography demonstrates a thin walled cystic mass with low level echoes and through transmission in the left adnexa. the right ovary and uterus appear normal. whats the dx?

endometrioma

The sonographic images of a unilateral ovarian mass in a 25y.o woman with menstrual irregularities demonstrate a well-defined, 5.0cm homogenous unilocular mass containing low-level internal echoes and posterior acoustic enhancement. these findings are most consistent with which ovarian pathology?

endometrioma

A 19y.o woman is seen in her obstetricians office 1 week after C-section. the C-section was urgent in nature and was performed at 27w3d gestational age for ruptured membrane, breech presentation, and extended period of fetal HR decelerations. the patient states that she has had increasing uterine tenderness over the last few days, which is now severe. she also says that she has had very minimal bleeding but a foul-smelling discharge and fever. the patient has no hx of pelvic infections in the past. whats the dx?

endometritis

A 45y.o woman with mild pelvic discomfort undergoes a sonographic exam, and a 3.0cm hypoechoic solid ovarian mass discovered. the images also demonstrate ascites and marked attenuation posterior to the mass. whats the dx?

fibroma with Meig's syndrome

A pediatric patient with elevated estrogen levels is referred for a pelvic sonogram after receiving a dx of precocious puberty. a solid mass is discovered in the left adnexa, with no evidence of normal left ovary. whats the dx?

granulosa cell tumor

A 29y.o woman with LLQ pain is referred for a pelvic sonogram to rule out ovarian torsion. the images demonstrate a 4.0cm left ovarian mass containing a reticular pattern of echoes with posterior enhancement and peripheral ovarian flow by color doppler imaging. a follow up sonogram performed 2 months later demonstrates a normal left ovary and a 2.5cm dominant follicle on the right ovary. by the time of the f/u sonogram, the patient was asymptomatic. which of the following is the most likely dx for the first exam?

hemorrhagic ovarian cyst

The sonographic appearance of a copper wire IUD includes which of the following?

highly echogenic stem with intense posterior shadowing

A 37y.o woman is undergoing IVF. after receiving gonadotropins, her physician orders a transvaginal sonogram. the purpose of this exam is to?

measure follicle size

A 55y.o woman with stomach cancer is referred for a pelvic sonogram because of pelvic discomfort. the sonogram reveals bilateral solid ovarian masses. this finding is most consistent with which of the following?

metastatic tumors

A 45y.o woman undergoes a pelvic sonogram because of a family hx of ovarian cancer. her CA 125 levels are not elevated, and she is not experiencing any unusual symptoms other than weight gain. sonogram reveals a 15cm, predominantly cystic mass with multiple septations, several papillary projections, and low level echoes within the mass. color doppler imaging reveals vascularity within the solid components. given the patients hx and sonographic findings, whats the dx?

mucinous cystadenoma

A 27y.o woman complaining of severe pelvic pain undergoes a pelvic sonogram. the patient has a history of IUD insertion after her most recent pregnancy. the IUD is eccentrically located with the T-arm extending lateral to the endometrium. what is the most likely dx?

myometrial penetration

An adnexal mass is palpated in a 34y.o woman with pelvic pressure. pelvic sonography reveals a 4cm solid adnexal mass with a normal appearing ovary adjacent to the mass. What is the most likely dx?

pedunculated fibroid

A 27y.o woman with a hx of IUD insertion 6 months prior is seen now because the IUD strings are missing. her last menstrual period was 3 weeks ago. the sonogram reveals a normal-appearing uterus without evidence of an IUD within the pelvis. what is the most likely explanation regarding the IUD?

perforation of IUD into the peritoneal cavity

A 32y.o woman is seen by her gynecologist in the office for pelvic pain. she describes the pain as chronic that comes and goes. on pelvic exam, there is fullness in the right adnexa. the patient has no hx of PID or IUD use but has had previous surgery for an ovarian cyst. endovaginal sonography shows a completely anechoic structure near the right ovary, but the uterus and ovaries appear normal. what is the dx?

peritoneal inclusion cyst

A 45y.o with menorrhagia undergoes a pelvic sonogram that reveals a multioculated cystic mass adjacent to the right ovary. the patients medical hx includes prior pelvic surgery for endometriosis 15 years ago. the patient denies any RLQ pain. whats the dx?

peritoneal inclusion cyst

A patient with an IUD in place has a positive pregnancy test. a sonogram reveals a 7-week, viable gestation within the uterus. the IUD is identified in the lower uterine segment; however, the strings are not visible to the obstetrician. leaving the IUD in situ during the pregnancy increases the risk for which one of the following complications?

preterm labor

Pelvic sonography is requested for 45y.o, postmenopausal woman who has a hx of chronic right pelvic discomfort. the patient states that she has a hx of endometriosis but denies a hx of PID. sonography shows an anechoic tubular structure between the uterus and right ovary, but there are no signs of hyperemia. whats the dx?

right hydrosalpinx

A 38y.o woman presents to the ER complaining of intermittent right adnexal pain for the last 2 weeks. the pain became severe the night before following intercourse, but the symptoms have slightly improved today. the patient states that she has a hx of endometriosis. the pelvic exam reveals mild adnexal tenderness. the right ovary appears normal on pelvic sonography, but a moderate amount of adjacent fliud with internal echoes is identified. neither color nor spectral doppler was performed. the report states suspicion of a right TOA, but the lab test results are normal. whats the dx?

ruptured endometrioma

For evaluation of infertility, three dimensional ultrasound of the pelvis has the most utility for the dx of?

septate uteri

A 30y.o woman with menorrhagia undergoes a pelvic sonogram that reveals a hypoechoic mass distorting the endometrium. this mass attenuates the sound beam, it has a broad base, and the endometrium courses over it. what is the most likely dx?

submucosal fibroid

A 42y.o woman with a history of breast cancer undergoes a pelvic sonogram, which demonstrates cystic changes within the endometrium. which of the following is the most likely dx of the endometrial appearance?

tamoxifen changes

A 25y.o woman is referred for a pelvic sonogram because of LLQ pain. a pregnancy test is negative. the sonogram reveals 2.0 cm unilocular, simple cyst adjacent to the left ovary. Which of the following statements is true regarding this finding?

this most likely represents a paraovarian cyst, and no treatment is necessary

A pelvic sonogram is performed on a 33y.o woman with pelvic pain. she describes the pain as a constant dull ache that seems to increase when standing. transabdominal sonography shows an enlarged, fibroid uterus, normal ovaries, and bilateral cystic areas that appear to be tubular. what should the sonographer do next?

use color doppler to see if the tubular structures are prominent veins

A 13y.o girl started menses 6 months ago and has cyclic pain on the left side during menses. on the sonogram, an endometrial echo is present in addition to a thick walled oblong mass attached to the uterus on the left side. whats the dx?

uterus didelphys

Which uterine anomaly is always characterized by two cervices and two vaginas?

uterus didelphys