Shannon MacDonald ihuman Inability to Become Pregnant

Reason for encounter

Inability to become pregnant

History of Present illness (HPI)

Shannon MacDonald is a 27-year old female who presents today for evaluation of difficulty getting pregnant for the last 2 years despite regular intercourse. She acknowledges menstrual irregularities which have been getting shorter as she grows older, currently lasting 2-3 days from the initial 5 days. Besides, her periods have become unpredictable skipping 1-2 months. Patient engages in physical activities/exercise, running 15 miles weekly for marathons. She is fatigued most of the time but she denies infertility among close female relations, history of fibroids, ovarian tumors, cancers, or cysts, denies bleeding during or after intercourse, denies spotting a few days before the start of her menstrual period.

Physical Exam

Blood pressure
Pulse
Respiration
Temperature
SPO2
Visual inspection abdomen
Palpate abdomen
Palpate neck
Auscultate lungs
Auscultate heart
Breast exam
Auscultate abdomen
Genitourinary female exam
Inspect/palpate head
Inspect mouth/pharynx
Reflexes – deep tendon
Visual inspection extremities
Inspect nails
Inspect hair color, distribution, thickness

Case Problem Statement

The patient is a 27 year old thin female recreational marathon runner (BMI+17) with a chief complaint of inability to become pregnant after trying for two years. She relates a history of worsening fatigue, headaches, oligomenorrhea, irritability, unintentional weight loss and thinning hair. Physical exam reveals an enlarged thyroid with thrill and bruit, tachycardia, hyperreflexia, fine resting tremors, lateral eyebrows thinning and onycholysis on her ring fingernails. PMH significant for appendectomy and ex-smoker. Husband’s sperm analysis was low normal per report she brought with her.

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Objective Data

General: AOX4, well groomed, no body odor, vital signs within normal limits, in no pain or respiratory distress,

HEENT/Neck: Head: normocephalic, atraumatic. Eyes: PERRLA, thinning lateral eyebrows, no periorbital edema or evidence of subconjunctival hemorrhage. Ears: no edema or deformities, no exudates, fluid, or inflammation surrounding the inner ear or tympanic membrane, hearing is bilaterally intact. Nose/Mouth/Throat: no polyps/discharge, normal oropharynx, pink and moist membranes, no pain with chewing. Neck: freely mobile and midline trachea, 45gm thyroid in size (enlarged), palpable thyroid thrill and bruit, full range of motion (FROM), no jugular venous distention (JVD) or carotid bruits.

Cardiovascular: Tachycardia (PR 102bpm, regular), S1 & S2 heard no pain with chewing, no gallops, rubs, or murmurs. Normal color for ethnicity in feet, hands, and lips. No edema in hands, face, upper or lower extremities.

Chest/Respiratory: RR 18bpm, regular, chest wall is symmetrical, no palpable masses or lumps, no nipple discharge, resonant anterior lung fields, clear breath sounds on auscultation, no rhonchi, rales, crackles or wheezing.

Abdomen: flat & non-distended, no scars, protruding masses or tumors. Present and active bowel sounds in all quadrants, no abdominal or femoral bruits, no hepatosplenomegaly, no tenderness or rebound tenderness, no tympany, guarding, or shifting dullness.

Skin: warm & dry, no lesions, capillary refill<3seconds, normal hair color, thickness and distribution. Bilateral onycholysis in ring fingers, blanching observed.

Management Plan

Additional diagnostic tests

None

Medications

Propranolol 10-40mg PO 6-8 hourly (Bartalena et al., 2022).
Propylthiouracil 50-150mg PO 8 hourly with dose adjustments based on follow up tests

Consults/Referrals

Endocrinologist consult for specialized management of Grave’s disease and long-term follow up
Gynecology consult for conception planning and follow up

Client Education

You have been diagnosed with graves’ disease which is a thyroid disorder resulting from an overactive thyroid leading to the overproduction of thyroid hormone with symptoms such as weight loss, heat intolerance, or a fast heartbeat (Bartalena et al., 2022). Thyroid hormones play a major role in regulating the menstrual cycle and when the thyroid is overactive, menstrual cycles become irregular or stop, making it difficult to conceive (Bartalena et al., 2022). If left untreated, it can lead to osteoporosis, thyroid storm, eye problems (graves orbitopathy), and heart complications (atrial fibrillation) (Bartalena et al., 2022).
Management of graves’ disease has different approaches; medical therapy with methimazole or propylthiouracil (PTU), radioactive iodine ablation, and thyroid surgery (Bartalena et al., 2022). Radioactive iodine ablation and methimazole are contraindicated in pregnancy.
It is important to undergo medical therapy with PTU before conception to achieve a euthyroid status and reduce fetal risks and miscarriages.
For good outcomes, it is necessary to take the medications as prescribed with regular monitoring for side effects

Follow up

Return for follow up in 4-6 weeks for follow-up; medication adjustments, review of symptoms, TFTs (free T4, free T3, TSH).
Follow up with endocrinology and gynecology post discharge

Reference

Bartalena, L., Piantanida, E., Gallo, D., Ippolito, S., & Tanda, M. L. (2022). Management of Graves’ hyperthyroidism: present and future. Expert Review of Endocrinology & Metabolism, 17(2), 153-166. https://doi.org/10.1080/17446651.2022.2052044

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Index of Exercises

A young couple is having difficulty conceiving a child. Their physician explains some of the normal processes that must occur for a pregnancy to result:

The penile urethra enclosed by the corpus cavernosum must be patent.
Sympathetic stimulation must lead to erection of the penis
Parasympathetic stimulation must lead to ejaculation of semen.
Fertilization must occur in the ampulla of the uterine tube

A 21-year old woman asks about her first biannual pelvic examination, and it is explained to her that the normal position of the uterus is.

Anteflexed and anteverted
Retroflexed and anteverted
Anteflexed and retroverted
Retroverted and retroflexed
Anteverted and retroverted

A 22 year old woman received a laceration through her inguinal canal about 1 inch lateral to the public tubercle. Which of the following ligaments is lacerated within the canal?

Suspensory ligament of the ovary
Ovarian ligament
Mesosalpinx
Round ligament of the uterus
Rectouterine ligament

A 37- year old male construction worker receives a deep penetrating wound in the pelvic cavity resulting in a lesion of thee sacral splanchic nerves. Which of the following nerve fibers would primarily be damaged?

Postganglionic parasympathetic fibers
Postganglionic sympathetic fibers
Preganglionic sympathetic fibers
Preganglionic parasympathetic fibers
Postganglionic sympathetic and parasympathetic fibers

Female infertility can have many causes. If the positive feedback of estrogen on the hypothalamus and pituitary is blocked during a menstrual cycle, which of the following consequences will occur: (There are three correct answers and you will receive 1 point for each correct answer. If you select more than three choices your score will be 0)

Decrease amplitude of the LH surge
Decreased follicular estrogen production
Increased progesterone production
Decreased follicular production of prostaglandins
Increased androgen production in granulosa cells
Increased human chorionic gonadotropin production

It is expected that when the patient’s problem is corrected she will be able to become pregnant. During any pregnancy, if the rate of increase in the concentration of CRH is decreased the consequence will be:

Increased duration of her pregnancy (late delivery)
Premature birth (shortened duration of pregnancy)
No effect on the length of term since the changing concentration of oxytocin determines when full term has occurred.

Male fertility can arise because of defects in the production of the sex hormones required for production of viable sperm. Which of the following hormones must be present in the testes for normal spermatogenesis to occur? (There are three correct answers and you will receive one point for each correct choice. If you select more than three choices your score will be zero).

GnRH
LH
FSH
Testosterone
Estrogen

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