[Dr. N Elham]

A 33-year old woman comes to the physician because she has not had a menstrual periods for 6 months. Prior to this she had normal period every 29 days that lasted 4 days. She has noted some weight gain in the past few months. She has a history of hepatitis A infection 6 years ago and had an appendectomy at age 12. She takes no medications and has no allergies to medications. Her father died of acute pancreatitis 3 years ago. Her mother is alive and well with no medical problems. Which of the following is the most appropriate next step in diagnosis?

a- Amylase
b- FSH
c- Beta hCG
d- LFTs
e- TSH

After I had a careful analysis of this question, I selected option e as an answer. Because hypothyroidism can be a reversible cause of amenorrhea, however, the explanation of this question states that the correct answer is option c. The reason they mention is that every time we encounter a case of amenorrhea, we have to rule out pregnancy first. By the way I knew this fact, but why I didn't chose it was the fact that if a woman has amenorrhea for 6 months, this will mean that the size of the fetus would have been obvious and huge in case of pregnancy). So I chose the option e as answer.
What do you guys think am I right or the kaplan q book?

why does kaplan make such questions??????????

 

[khanar]

Disagree

They told you that she has noted some weight gain, that should be enough for you to suspect pregnancy.
Not all woman have significant abdominal distension at 20 or 24 weeks gestation.
A rule is rule, you have to exclude pregnancy first in any reproductive female with amenorrhea.

 

[Med_iq]

I think the pt presentation rules out pregnancy. She had 6 missed periods and no fetal movement. I would choose E as an answer.

 

[shakaib]

Shakaib

yeah even there are evidence going more towards thyroid problem but if we consider this as a women coming to our clinic with such scenario first we will order B-hcg first at least to confirm she is not pregnant ...

 

[esmymeshmohm]

this can be ectopic pregnancy

I don't think this question is strange ,,, this can be a case of ectopic pregnancy ,,, the effect of Progesterone will cause the weight gain ,, there will be increase in the size of the uterus by the effect of progesterone (although the uterus is empty)

 

[1TA2B]

Good learning point.

Yes. "must exclude pregancy in case of amenorrhoea in a woman of reproductive age".

Thanks Dr. N Elham for sharing with us.

 

[healer2b]

It's also important to remember that ruling out pregnancy is cheap, painless, and fast, while the other tests may be more expensive and invasive, not to mention the "high cost" of embarrassment for missing a pregnancy...

 

[Seetal]

hmm... tricky

I don't think this question is strange ,,, this can be a case of ectopic pregnancy ,,, the effect of Progesterone will cause the weight gain ,, there will be increase in the size of the uterus by the effect of progesterone (although the uterus is empty)

yes i went for E too but then u reminded me. ectopic pregnancy doesnt have to be in the tubes. it could well be in the peritoneum. in tht case, weight gain without obvious uterine enlargement is possible.

also, a pregnancy test is the cheapest test ever. do it with ANY case of ammenorrhea.

and at some point, we should also note the difference in diagnostic tests between the USA and other countries. for example, women with breast lumps where there is a suspicion of tumor, are sent for an ultrasound in some countries where a mammogram isnt easily available, while in the USA, a mammogram is the FIRST thing u choose (unless of course, its a mastitis).
or like the management of an intussussception for example, where a barium enema isnt available, patients are taken straight into the OR.

 

[Drkelany]

First thing is to rule out pregnancy by B hcg