Virginia II: Later On

Female Reproductive System & Breast


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/G8_F17.jpg"}},{"insert":"\n\nYou finish reading the referral letter and look at the couple in front of you\u201432-year-old Virginia and her husband.\n\nVirginia delivered her fifth child vaginally a month ago. The child was healthy, but Virginia experienced primary postpartum hemorrhage due to uterine atony. After uterine massage and multiple uterotonics failed to halt the bleeding, it was finally arrested by hemostatic brace suturing. Virginia recovered rapidly afterwards and was sent home after several days.\n\nHaving had four other children before, the postpartum period\u0027s challenges were nothing new to Virginia. Everything went smoothly at first\u2014but after a couple of weeks, she found it harder and harder to breastfeed her baby.\n\nAfter assistance from her midwife proved to be unsuccessful, Virginia\u0027s obstetrician referred her to a lactation consultant. The consultant couldn\u0027t help either\u2014but she did notice that the underlying issue seemed to be inadequate milk production, rather than poor breastfeeding technique. \n\nTherefore, the obstetrician decided to refer Virginia to your clinic, to exclude a potential medical cause for her lactation failure.\n"}]}


{"ops":[{"insert":"You carefully elicit a history from Virginia and find out that she had no trouble breastfeeding her previous four children. Her medical, surgical, drug, and family histories are all unremarkable.\n\nThe general examination is normal. Breast examination is also normal\u2014except that when you ask Virginia to elicit nipple discharge, she is unable to do so in either breast. Examination of the heart, lungs, and abdomen is unremarkable. Neurological examination is also unremarkable. For completeness, you perform a mental state examination, but this too is normal.\n"}]}


{"ops":[{"insert":"History and examination over, you ponder what to do next.\n\nWhich of the following will you do?\n"}]}
1. Refer Virginia to a psychiatrist
2. Refer Virginia back to her obstetrician
3. Order an endocrine profile