further questioning

SOCRATES

S - where is the pain, if there's pelvic pain (if present)

O - last period stop when and how long (regular or not before)

C - hirsutism, acne, heavy bleeding, any discharge, frequent period cramps

R - back pain when period cramps

A - hirsutism, acne, visual disturbances, headache, weight changes, constitutional symptoms, galactorrhea, low libido, heat/cold tolerance, vaginal dryness, hot flashes, vomiting, nausea, dizziness

T - how long menstrual cycle

E - exercise, diet, stress (indicate hypothalamic changes)

S - how bad menstrual irregularity effect daily life

PMH

• past surgery(Asherman syndrome), contraceptive device/medication, diabetes mellitus, adrenal disorder before?, medication (anti-depression, anti-psychotic, anti-hypertensive), past chemo/radiation therapy

pregnancy and menstrual history

• lactating mother?

• how many pregnancy before

• how many successful delivery

social history

• occupation (stressful?)

• diet

• alcohol intake

• smoking

FH

• family member with same problem?

even though all tests came back negative.

• infertile or not ( 12 months without contraceptive )

• before this her husband proven fertility

• significance weight gain + could be insulin resistance

• false pregnancy= pseudocyesis( could be stress or something )

  
  

Past Medical History: She had acne from age 20, visited

dermatologist. Started laser hair removal on face from the age 25.

• hormonal imbalance

• she had hirsutism, acne indicate hyperandrogenism

Menstrual history: She stated that her menses were irregular,

occurring every 25 to 47 days, and sometimes she skipped menses altogether. They were sometimes heavy, other times light with just brown spotting. She noted that her menses had always been this way,ever since menarche at age 12.

• irregular period cycle ( anovulation )

• oligomenuria

• irregular bleeding

• chronic

• 
  

Family History: her mother had HTN, type 2 diabetes, and obesity.

• insulin resistance , risk factor for pcos

• metabolic syndrome

• 
  

Social History: married at the age 24, no children. Sexually active since 24 with no history STI’s. She never smoked or consumed alcohol.

• infertility not due to sti

• no life style risk factor

• 
  

Medications. The patient was not on any type of contraception and did not take any medications.

• no drug induce amenuria

Futher investigation

1. vital sign

2. general PE ( cushing = moon face . PCOS= hirsutism, )

3. abdominal exm

4. random blood glucose

5. HbA1c

6. pelvic exm

7. breast exm ( prolactin )

8. dexamethasone suppression test

9. 
   

10. 
    

• normal

Heart rate 78 beats per minute 60 – 100 beats per minute

• normal

Respiratory rate

14 breaths per minute 12 – 16 breaths per minute

• normal

Bloodpressure

140/90 mmHg 120/80 mmHg

• high bp ( hypertension )

BMI 31 kg/m2 (normal range: 18.5 – 24.9 kg/m2)

• obese ( class 1)

On examination there is excessive hair growth on the lower arms,legs and thighs and in the midline of the abdomen below the umbilicus. There is a small amount of growth on the upper lip too. The skin of her neck was darkish and looks velvety. The abdomen was soft, and no masses were palpable. Her pelvic examination was limited by her obesity but normal.

• indication high androgen

• hirsutism

• acanthosis nigricans = insulin resistance

• no pregnancy ,

• hard to detect ovarian bulge by palpation

On speculum examination. The vagina was normal pink, soft,

rugosed and no lesions were found.

• no vigina ptlhgy

futher questioning

1. dexamethasone supression test

2. ultrasound

3. more than 12 folicle in each ovary

4. ovarian vlm more that 10 ml

5. blood test ( testosterones & DHEAS)

6. oligo ovulation and oligomenorhea

7. 
   

(FSH)

7 IU/L Day 2–5 1–11 IU/L

• normal

Luteinizing hormone (LH) 12 IU/L Day 2–5 0.5–14.5 IU/L

• normal

Prolactin 780 mu/L 90–520 mu/L

• high

Testosterone 3.2 nmol/L 0.8–3.1 nmol/L

• high

DHEAS 3.92 to 10.66

• high

μmol/L 11.08 μmol/L

Thyroid-stimulating

hormone 4.9 mu/L 0.5–5.7 mu/L

• normal

Free thyroxine 14.7 pmol/L 10–40 pmol/L

• normal

The pregnancy test Negative

• no pregnancy

Transvaginal ultrasound revealed enlarged both ovaries (right 11.5 ml and left 12.3 ml) with more than 15 small follicles in each ovary arranged in a periphery

with central echogenic stroma.

• meet the criteria of pcos

The diagnosis of polycystic ovarian syndrome was made.

• PCOS

Management: The patient was started treatment with letrozole and metformin combination for ovulation induction. She also advised exercise and calorie-restricted diet.

• letrozole = aromatase inhibitors ( induce ovulation )

• metformin ( insulin sensitization)

• management ( for life style )

FINAL DIAGNOSIS

• PCOS