2013 Case of the Month Archive

Test Your Knowledge!

02-2013 Case of the Month

A 30-year-old woman, para 1, presents with a 3-cm Type II submucosal fibroid. Six months ago she had a miscarriage at 13 weeks' gestation and a sonohysterogram revealed the fibroid. She is considering another pregnancy but is unsure if she should treat the fibroid first. She wants to know what her risks of obstetric complications would be with a fibroid and with her fibroid treatment.

What would you do?  

A. Explain that hysteroscopic myomectomy is associated with the lowest risk of complications compared to other intrauterine surgical procedures.

B. Tell her that fibroids are not related to miscarriage.

C. Let her know that fibroids double the risk of placental abruption.

D. Explain that the miscarriage rate is higher for myomectomy than uterine artery embolization.

03-2013 Case of the Month

A 35-year-old very muscular man presents with low libido and fatigue. He is a former competitive bodybuilder, but claims to have been “all natural” throughout his career. His total and free testosterone levels are very low. You decide to further investigate his hormonal balance by checking gonadotropin levels. Which combination of gonadotropins is most consistent with current anabolic steroid use? 

Choose your answer: 

A. Elevated FSH and normal LH 
B. Elevated FSH and low LH 
C. Elevated FSH and elevated LH 
D. Low FSH and low LH 

04-2013 Case of the Month

A 50-year-old diabetic woman who has had a total abdominal hysterectomy presents with intractable night sweats that are not relieved by lifestyle measures. Her body mass index is 22 kg/m2 and she is a non-smoker.

Choose your answer:  

A. Non-hormonal therapy with gabapentin 
B. Conjugated estrogens 0.625 mg 
C. Transdermal estradiol 50 mcg 
D. Micronized progesterone 300 mg nightly

05-2013 Case of the Month

A 6 year/10 month-old African-American female presents with her mother who is concerned about her daughter’s recent breast development in the last few months. The child has no other medical problems or history of surgery. The family history is negative for breast, ovarian and colon cancer. Of note, the mother reports her own menses began at age 9 years and her adult height is 5’6” (167.5 cm). On examination, you note the child is in the 60th percentile for height and weight. She has Tanner 2 breasts and Tanner 1 genitalia. The external genitalia appear normal.

What do you do next in evaluating this child?

A.Bone age of hand and wrist
B.Pelvic ultrasound
C.Gonadotropin-releasing hormone (GnRH) stimulation test
D.Reevaluate in 2 years to assess progression of puberty
E.Adrenocorticotropic hormone (ACTH) stimulation test
F.Computerized tomography (CT) of the abdomen

06-2013 Case of the Month

A 31-year-old woman (gravida 2, para 1) presents to your office at 6 weeks’ gestation.  She is complaining of vaginal bleeding and pelvic pain.  You perform an evaluation and management (E&M) service and ultrasonography and diagnose an ectopic pregnancy.  After discussing the options with her, you perform a laparoscopic salpingectomy on her later that afternoon. 

How would you code this?

A.Code only for the laparoscopic salpingectomy since the E&M service and ultrasonography are within the global period and therefore part of the global surgical package.

B.Code for the laparoscopic salpingectomy and the ultrasonography but not the E&M service since the E&M service is within 24 hours of the surgery and therefore part of the global surgical package.

C.Code for the E&M service, the ultrasonography, and the laparoscopic salpingectomy separately.  I may have to appeal the denial of the E&M service if the third party payer considers it part of the global surgical package.

D.Code for the E&M service, the ultrasonography, and the laparoscopic salpingectomy separately. I would place the -57 modifier on the E&M service to signify that this was the E&M service that resulted in the decision for surgery.  I would expect to be reimbursed for all 3 procedures since the decision for surgery is never part of the global surgical package.

E.Wait for the operative note to arrive in my office and my staff would code for the procedure.

07-2013 Case of the Month

Your IVF center has decided to go to blastocyst culture whenever possible and the laboratory has become much busier in the last several days. You notice that you have more embryos in the incubator now for a longer period of time and have to open the incubators more frequently now that you are trying to go to Day 5. You notice that the rate of embryonic development and particularly the rate of blastocyst development is beginning to decline. This is noticeable in all patient age groups as well as with the donor oocyte cases. 

What is the most likely reason? 

A.The media has gone bad.

B.The pH and temperature values in your incubators are probably fluctuating too much due to increased opening(s) of the incubators.

C.The water pans need to be changed more often.

D.The drops you are using for embryo culture are too big.

08-2013 Case of the Month

A 38-year-old, recently-married female who strongly desires childbearing has been diagnosed with a malignant gynecologic cancer and asks about her options for surgery and future fertility. 

For which one of the following malignant diagnoses would you consider a fertility-sparing surgical approach?

A. Stage IA2 small cell cervical cancer
B. Stage IIB cervical squamous cancer
C. Grade 3 endometrial cancer
D. Stage IB1 cervical adenocarcinoma

09-2013 Case of the Month

Assisted reproductive technology programs must maintain compliance with US Food and Drug Administration (FDA) regulations. 

Following an inspection of your clinic’s donor program, which of the following would result in an FDA action?

A. The disease-testing lab is utilizing NAT testing for HIV.
B. The disease-testing lab is utilizing total antibody screening tests to test for Hepatitis-B Core.
C. There has not been a satisfactory response to a 483 issuance.
D. The lab has been following the clinic’s standard operating procedures (SOPs).
E.  The lab has been providing documentation for donation(s) proving the clinic SOPs have been followed.

11-2013 Case of the Month

A patient who recently moved from another state comes to your clinic for transfer of her 3 cryopreserved embryos from a previous cycle. The embryos have been shipped to your center and are ready for thaw and transfer. Slow freezing was used for cryopreservation.

What do you do?

A. Use a very high warming rate.
B. Utilize your laboratory’s standard warming protocol as that is what your laboratory personnel are most skilled with.
C. Obtain the thaw protocol from the clinic sending the embryos and follow it. 
D. Increase the sucrose concentration in the thaw solutions.

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