- Clinical Findings
- Etiology
- Pathology
- Epidemiology
- Management & Treatment
- Prevention
- Complications
- Prognosis
- Research Frontier
- Clinical Case Studies
- Study Questions
Symptoms
hyperandrogenism, amenorrhea or oligomenorrhea, and the ultrasound appearance of polycystic ovaries.
Approximately half of patients with PCOS are obese, and abnormalities in insulin dynamics are common, as is metabolic syndrome. Symptoms generally begin shortly after menarche and are slowly progressive. Patients may develop dysfunctional uterine bleeding as defined by frequent or heavy uterine bleeding. A major abnormality in patients with PCOS is the failure of regular predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or Prometrium, 200 mg daily for 10–14 days of each month). Oral contraceptives are also useful for management of hyperandrogenic symptoms, as is spironolactone, which functions as weak androgen receptor blocker. Clomiphene and letrozole are used in PCOS patients who are interested in fertility. Corticosteroids will worsen this patient’s obesity and hyperglycemia. Testosterone will worsen the PCOS because the disorder is driven by androgen excess.
Signs
Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.
In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure. These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.
Infection in the kidneys may spread to the bloodstream—a serious condition called sepsis—though this is also uncommon.
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You are evaluating a 23-year-old woman with heavy uterine bleeding. She reports menarche at age 13 with regular monthly 5–6 days menses until the age of 19. Starting at age 20, she began having three to four menses per year only lasting 3 days. For the last year, she has had four episodes of heavy uterine bleeding lasting 6–8 days. She has not had any menstruation for 9 months and is not sexually active. She has been diagnosed with type 2 diabetes and takes metformin. On examination, she is mildly hirsute, her blood pressure is 130/85 mmHg with heart rate of 85 bpm and respiratory rate of 14 breaths/min. Her BMI is 25 kg/m2, and her SaO2 on room air is 98%. Her β-gCG is negative, testosterone is elevated, and vaginal ultrasound reveals polycystic ovaries. Which of the following is the most effective treatment for her uterine bleeding?
The correct answer is D. You answered A.
The answer is D. Polycystic ovarian syndrome (PCOS) is diagnosed based on a combination of clinical or biochemical evidence of hyperandrogenism, amenorrhea or oligomenorrhea, and the ultrasound appearance of polycystic ovaries. Approximately half of patients with PCOS are obese, and abnormalities in insulin dynamics are common, as is metabolic syndrome. Symptoms generally begin shortly after menarche and are slowly progressive. Patients may develop dysfunctional uterine bleeding as defined by frequent or heavy uterine bleeding. A major abnormality in patients with PCOS is the failure of regular predictable ovulation. Thus, these patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia associated with unopposed estrogen exposure. Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate, 5–10 mg, or Prometrium, 200 mg daily for 10–14 days of each month). Oral contraceptives are also useful for management of hyperandrogenic symptoms, as is spironolactone, which functions as weak androgen receptor blocker. Clomiphene and letrozole are used in PCOS patients who are interested in fertility. Corticosteroids will worsen this patient’s obesity and hyperglycemia. Testosterone will worsen the PCOS because the disorder is driven by androgen excess.
A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?
The correct answer is A. You answered A.
Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.
Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?
Aortic root size
Left atrial size
Pulmonary artery pressures
Pulmonic valve function
Tricuspid valve regurgitation
The correct answer is A. You answered A.
The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.
A 32-year-old woman with a long history of irregular menstrual periods visits her physician for consultation. She is married for 8 years and has been unable to conceive. Her menstrual period occurs once every 2-4 months. She had normal Pap smear last year. Her height is 5.2". Her weight is 205 pounds. Her vital signs are within normal limits. She has acne and excessive facial hair.
This patient is at risk of which one of the following diseases?
A- Lung cancer
B- Cervical cancer
C- Ovarian cancer
D- Endometrial cancer
E- Liver cirrhosis
The correct answer is D
This patient is most likely has polycystic ovarian syndrome (PCOS) which is characterized by infertility, oligomenorrhea, obesity and hirsutism. Lack of menstrual cycles due to failure of ovulation leads to low level of progesterone and unopposed estrogen. Prolonged exposure of unopposed estrogen put this woman at high risk of endometrial cancer.