CASE 1

For the first case this morning, we have AA, who is a 30 year old housewife from Manila
who is married for 4 years with a chief complaint of infertility for the past 3 yrs. There were
no symptoms of dyspareunia and post coital bleeding and her husband is a 35 year old
engineer who was noted to be healthy with no mentioned previous partner. Sexual
intercourse of two times a week was noted with no history of contraceptive use.
Review of symptoms was unremarkable with last menstrual period noted on July 27, 2021
and previous menstrual period last week of June. AA has normal interval, duration, and
amount of menses with noted mild dysmenorrhea only on the first day.
Her past medical history denotes that she had a previous appendectomy last 2016 due
to a ruptured appendix with no noted complications. She also has updated HPV and
COVID vaccinations with unremarkable family history. On physical exam, a suprapubic
transverse incision scar on the abdomen, noted to be a Pfannenstiel incision was seen
from the previously performed appendectomy. Usually a mcburney’s incision is performed
for appendectomy.
For this case, the clinical impression is G0P0 primary infertility due to postoperative
adhesions from previous appendectomy.
• External genitalia: inverted triangle pattern; no lesions, scars, erythema,
bleeding nor discharge
• Speculum exam revealed: cervix pink smooth no discharge noted; vaginal walls
smooth
• Internal examination showed: cervix firm long closed, uterus normal in size, no
adnexal masses nor tenderness
A semen analysis is first requested to check for male factors that may contribute to the
infertility and the husband is asked to abstain from sexual intercourse and ejaculation 3
days prior to collection. It is emphasized in the discussion that the Catholic way of
obtaining specimen would be to use a perforated condom with the intention that possible
pregnancy can occur. Whatever is collected from the condom will be brought to the lab
for analysis. The results of the semen analysis were presented where it showed a low
sperm count and decreased motility, denoting oligoasthenospermia.
• Other option: post coital test: Couple performs coitus → wife goes to the lab and
sperm is collected at her endocervical area
Test for patency of the fallopian tubes is also indicated in this case as the patient had a
history of appendectomy due to rupture of the appendix which can predispose to bacterial
spread and infection of the fallopian tubes. Peritoneal adhesions between the fallopian
tubes and ovaries can also affect the transport of the ovum to the tubes. So a
hysterosalpingography was requested, making sure that the patient had no active
bleeding, no active lower or upper genital tract infection, and had no allergy to the dye
used. Prophylaxis of doxycycline 100 mg 2x a day for 4 days should also be done. The
patient’s hysterosalpingography result was presented where it showed patent fallopian
tubes with spillage of the dye into the peritoneal cavity for both ovaries.
In this case, since the husband presented with oligoasthenospermia, management would
be referral of the husband to the urologist or infertility clinic for further evaluation.
CASE 3
RB, 22 yr old, nulligravid, with CC of a painful mass palpated on the left lower area since
3 days ago with no vaginal discharge and no associated urinary frequency, difficulty in
defecation or pelvic heaviness. It was noted during the discussion that the historian
should not ask anymore for the consent of the patient as it is already implied and we
should go straight ahead with the patient’s name, age, and chief complaint. Also, we
shouldn’t be asking details that can already be appreciated in the physical exam. In the
review of systems, there’s no need to be very detailed and only ask questions pertinent
in relation to the patient’s age, chief complaint, and possible diagnosis in order not to
bombard the patient.
On pelvic examination, a lesion was seen on the left labia majus at 5 o clock position and
it was noted to be tender but not warm to touch with no yellowish discoloration or
appearance of any abscess. With this, the clinical impression is a bartholin’s duct cyst
with fibroma and lipoma as possible differential diagnoses. In comparison to a bartholin’s
duct cyst which usually occur at the 5 or 7 o clock position, fibroma can occur anywhere
even in the cervix while a lipoma can also occur anywhere except the cervix and vagina.
• Bartholin cyst – most common large cyst of vulva; contains sterile mucinous fluid
(if not inflamed)
• Fibroma – harder, commonly found in labia majora, arise from deeper connective
tissue, slow growing
• Lipoma – soft, yellow, lobulated, and larger than fibroma, common periclitorally
and within the labia majora, slow growing with low malignant potential
For this patient, only a urinalysis may be needed to check for other possible source of
infection.
For the management, warm compress may be given but in order to alleviate the pain and
discomfort of the patient, marsupialization must be performed in order to drain the
contents of the cyst and prevent it from enlarging.
• No need for antibiotics since not inflamed
• Pain is due to the rapidly growing cyst that is stretching the thin skin of the vulva
(which is not easily distensible).
• Vulva is not distensible – if gradually increasing so there is time for skin on vulva
to adjust to it