# Clinical Cases: Gynecologic History and Examination

## Case 1: Abnormal Pap Smear with HSIL

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Dental hygienist

### Chief Complaint
"I got a call that my Pap smear was abnormal and I need to come in for more testing."

### History of Present Illness
The patient is a 32-year-old G2P2 who presents for colposcopy after an abnormal Pap smear. Her routine cervical cancer screening performed 2 weeks ago revealed high-grade squamous intraepithelial lesion (HSIL). She is understandably anxious and wants to know what this means and what to expect today.

### Gynecologic History
- Menarche: Age 12
- Menstrual cycles: Regular, 28-day cycles, 5 days of flow
- Last menstrual period: 10 days ago
- Prior Pap smears: Normal at ages 25, 28, 30
- HPV vaccination: Not vaccinated (not available during adolescence)
- Contraception: Copper IUD placed after last pregnancy
- STI history: Treated for chlamydia at age 22
- Sexual history: 3 lifetime partners, currently monogamous

### Obstetric History
- G2P2002
- Two uncomplicated vaginal deliveries at term

### Pap Smear Result
- **Cytology:** High-grade squamous intraepithelial lesion (HSIL)
- **HPV testing:** Positive for high-risk HPV (type 16 detected)

### Pre-Colposcopy Counseling
Explained to patient:
- HSIL indicates precancerous changes that require further evaluation
- Colposcopy involves magnified examination of the cervix
- Biopsies may be taken, which causes mild cramping
- This is NOT cancer, but needs treatment to prevent cancer

### Colposcopy Procedure

**Visualization:**
- Adequate colposcopy (transformation zone fully visible)
- IUD strings visualized, not removed

**After Acetic Acid (3-5%) Application:**
- Large area of dense acetowhite epithelium at 12-3 o'clock
- Sharp, distinct margins
- Punctation pattern visible (stippled appearance)
- Mosaic pattern at 2 o'clock
- No atypical vessels

**Schiller's Iodine (Lugol's):**
- Non-staining area corresponding to acetowhite lesion
- Confirms abnormal epithelium (lacks glycogen)

### Biopsies Taken
- Directed biopsies x 3 from most abnormal-appearing areas
- Endocervical curettage (ECC) performed

### Histopathology Results (1 week later)

**Cervical Biopsies:**
- CIN 3 (carcinoma in situ) at 12 o'clock position
- CIN 2 at 2 o'clock position
- CIN 2 at 3 o'clock position

**Endocervical Curettage:**
- Negative for dysplasia

### Diagnosis
**Cervical Intraepithelial Neoplasia 3 (CIN 3)**
- High-grade precancerous lesion
- HPV 16 positive (highest-risk type)
- No invasion on biopsy

### Treatment Recommendation
**Loop Electrosurgical Excision Procedure (LEEP)**

**Procedure Discussion:**
- Outpatient procedure under local anesthesia
- Wire loop removes transformation zone
- Provides tissue for histologic evaluation
- Confirms margins and rules out invasion
- High cure rate (>90%)

### LEEP Procedure (performed 2 weeks later)

**Findings:**
- Local anesthesia: Lidocaine with epinephrine
- Cervix visualized with colposcope
- Transformation zone excised with single pass
- Specimen oriented and sent to pathology
- Hemostasis with Monsel's solution
- EBL <5 mL

**LEEP Pathology:**
- CIN 3 present
- Margins: Negative (clear ectocervical and endocervical margins)
- No invasive carcinoma

### Post-Treatment Surveillance
- Counseled on importance of follow-up
- HPV/Pap co-testing at 6 months
- If negative, annual co-testing for 3 years
- Then return to routine screening if all negative
- Elevated cancer risk persists for 25 years; continued screening essential

### Clinical Image
![Colposcopy with HSIL](case_01_image.jpg)

**Image Description:** Colposcopic image of the cervix after application of acetic acid demonstrating a large area of dense acetowhite epithelium with sharp borders and punctation pattern, characteristic of high-grade cervical intraepithelial neoplasia.

**Attribution:** Image from Wikimedia Commons. Educational colposcopy image. Licensed under CC BY-SA 4.0.

---

## Case 2: Breast Mass Evaluation

### Patient Demographics
- **Age:** 45 years
- **Sex:** Female
- **Occupation:** High school principal

### Chief Complaint
"I found a lump in my left breast about 3 weeks ago."

### History of Present Illness
The patient noticed a firm lump in her left breast while showering. It has not changed in size over 3 weeks. She denies breast pain, nipple discharge, skin changes, or weight loss. She has never noticed a breast lump before. She is concerned because her mother was diagnosed with breast cancer at age 58.

### Breast History
- Last mammogram: 1 year ago, reported as BI-RADS 2 (benign finding - bilateral cysts)
- No prior breast biopsies
- No nipple discharge
- No breast surgeries

### Menstrual History
- Menarche: Age 11
- Currently perimenopausal with irregular cycles
- Last menstrual period: 6 weeks ago

### Family History
- Mother: Breast cancer at age 58 (deceased age 65)
- Maternal aunt: Ovarian cancer at age 62
- No known BRCA testing in family

### Risk Factors
- Early menarche (age 11)
- First pregnancy at age 32
- Family history of breast cancer (mother)
- Family history of ovarian cancer (maternal aunt)
- Dense breast tissue on prior mammogram

### Physical Examination

**Inspection:**
- No skin dimpling, retraction, or erythema
- Nipples symmetric, no inversion or discharge
- No peau d'orange appearance

**Palpation (Patient Supine, Arm Raised):**
- Left breast: 2 cm firm, fixed mass at 2 o'clock position, 4 cm from nipple
- Mass is irregular, non-tender, poorly mobile
- Right breast: No masses, mild nodularity consistent with fibrocystic changes
- Axillae: No palpable lymphadenopathy bilaterally

### Assessment
**Concerning left breast mass requiring urgent workup**

Red flags present:
- Fixed, irregular mass
- Poor mobility
- Family history of breast and ovarian cancer

### Diagnostic Workup

**Diagnostic Mammogram:**
- Left breast: Irregular, spiculated mass at 2 o'clock position
- Associated microcalcifications
- Right breast: Unchanged bilateral cysts
- **BI-RADS 5:** Highly suggestive of malignancy

**Breast Ultrasound:**
- Left breast: 2.1 cm irregular hypoechoic mass with angular margins
- Posterior acoustic shadowing
- No cystic component (solid mass)
- Left axilla: One lymph node with thickened cortex (suspicious)

### Tissue Diagnosis

**Ultrasound-Guided Core Needle Biopsy:**
- Left breast mass: 4 cores obtained
- Left axillary lymph node: Fine needle aspiration

**Pathology Results:**
- **Left breast:** Invasive ductal carcinoma, grade 2
  - Estrogen receptor: Positive (90%)
  - Progesterone receptor: Positive (70%)
  - HER2/neu: Negative
  - Ki-67: 15%
- **Axillary lymph node:** Positive for metastatic carcinoma

### Diagnosis
**Left Breast Invasive Ductal Carcinoma, ER+/PR+/HER2-, Clinical Stage IIA (T2N1)**

### Multidisciplinary Management
- Referred to breast surgeon and medical oncology
- Discussed surgical options (lumpectomy with radiation vs. mastectomy)
- Genetic counseling recommended given family history
- BRCA testing performed: BRCA1 mutation detected

### Treatment Plan
- Given BRCA1+ status: Patient elected bilateral mastectomy with reconstruction
- Sentinel lymph node biopsy (converted to axillary dissection for positive nodes)
- Adjuvant chemotherapy followed by hormonal therapy
- Discussion of risk-reducing salpingo-oophorectomy

### Teaching Points
- Any new, fixed, or hard breast mass requires urgent evaluation
- BI-RADS 4 and 5 require tissue diagnosis
- Core needle biopsy is preferred over excisional biopsy for diagnosis
- Family history of breast and ovarian cancer should prompt genetic testing consideration
- Triple assessment: Clinical exam + Imaging + Tissue diagnosis

### Clinical Image
![Breast Mass Mammogram](case_02_image.jpg)

**Image Description:** Mammographic image demonstrating an irregular, spiculated mass in the upper outer quadrant of the left breast with associated pleomorphic microcalcifications, classified as BI-RADS 5 (highly suggestive of malignancy).

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Henry Knipe. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/breast-carcinoma

---

## Case 3: Vaginitis Evaluation with Wet Mount

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Veterinary assistant

### Chief Complaint
"I have vaginal discharge and itching that won't go away."

### History of Present Illness
The patient presents with a 1-week history of vaginal discharge and intense vulvar itching. The discharge is thick, white, and "cottage cheese-like." The itching is worse at night and she has been unable to sleep well. She has tried over-the-counter yeast treatment (miconazole cream x 3 days) without improvement. She denies fever, abdominal pain, or dysuria. She is sexually active with one male partner (together 2 years) and uses oral contraceptive pills.

### Gynecologic History
- Menarche: Age 13
- Cycles: Regular with OCP use
- LMP: 1 week ago (finished period)
- Contraception: Combined OCP x 5 years
- STI history: None
- Sexual history: Monogamous, no new partners

### Past Medical History
- Recently completed antibiotics (amoxicillin) for sinusitis 2 weeks ago
- No diabetes
- No immunocompromising conditions

### Physical Examination

**External Genitalia:**
- Vulvar erythema and edema
- Excoriations from scratching
- No ulcers or lesions

**Speculum Examination:**
- Thick, white, curd-like discharge adherent to vaginal walls
- Vaginal erythema
- Cervix appears normal, no discharge from os
- No cervical motion tenderness

### Diagnostic Testing

**Vaginal pH:** 4.0 (normal: 4.0-4.5)

**Wet Mount Microscopy:**
- Saline prep: Epithelial cells present, no clue cells, no trichomonads
- 10% KOH prep: **Budding yeast and pseudohyphae present**
- Whiff test: Negative (no fishy odor)

**Findings Summary:**
| Test | Result | Interpretation |
|------|--------|----------------|
| pH | 4.0 | Normal (not BV) |
| Clue cells | Absent | Not BV |
| Trichomonads | Absent | Not trichomoniasis |
| Yeast/Hyphae | Present | Candidiasis |
| Whiff test | Negative | Not BV |

### Diagnosis
**Vulvovaginal Candidiasis (Yeast Infection) - Complicated**
- Severe symptoms
- Recent antibiotic use (predisposing factor)
- Failed initial OTC treatment

### Treatment

**First-line for complicated candidiasis:**
- Fluconazole 150 mg PO now, repeat in 72 hours (two-dose regimen)

**Adjunctive measures:**
- Cool compresses for vulvar discomfort
- Avoid scented products, douching
- Wear cotton underwear
- Return if no improvement in 1 week

### Patient Education
- Antibiotics disrupt normal vaginal flora, allowing yeast overgrowth
- This is not a sexually transmitted infection; partner treatment not needed
- Recurrent candidiasis (4+ episodes/year) may require suppressive therapy

### Follow-up
- Called patient at 1 week: Symptoms resolved
- Counseled on preventing recurrence with future antibiotic courses

### Differential Diagnosis Comparison

| Condition | Discharge | pH | Wet Mount | Odor |
|-----------|-----------|-----|-----------|------|
| **Candidiasis** | Thick, white, curd-like | Normal (4-4.5) | Pseudohyphae, budding yeast | None |
| Bacterial Vaginosis | Gray, thin, homogeneous | >4.5 | Clue cells | Fishy (positive whiff) |
| Trichomoniasis | Green-yellow, frothy | >4.5 | Motile trichomonads | May be fishy |
| Normal | Clear to white | 4.0-4.5 | Epithelial cells, lactobacilli | None |

### Clinical Image
![Wet Mount Candida](case_03_image.jpg)

**Image Description:** Microscopic image of a KOH preparation from vaginal discharge demonstrating budding yeast cells and pseudohyphae characteristic of vulvovaginal candidiasis. The branching pseudohyphae appear as elongated structures with visible septations.

**Attribution:** Image from CDC Public Health Image Library. Public domain.