CLINICAL & TEACHING CASES OBSTETRICS & GYNECOLOGy

CLINICAL & TEACHING CASES OBSTETRICS & GYNECOLOGy TABLE OF CONTENTS / LINKS TO INDIVIDUAL CASES 1. History 2. Examination 3. Pap Smear and Cultures 4. Personal Interaction / Communication Skills 5. Legal Issues / Ethics in Obstetrics & Gynecology 6. Preventive Care and Health Management 7. Maternal-Fetal Physiology 8. Preconception Care 9. Antepartum Care 10. Intrapartum Care 11. Immediate Care of the Newborn 12. Postpartum Care 13. Lactation 14. Ectopic Pregnancy 15. Spontaneous Abortion 16. Medical & Surgical Conditions in pregnancy 17. Preeclampsia-Eclampsia Syndrome 18. Isoimmunization 19. Multifetal Gestation 20. Fetal Death 21. Abnormal Labor 22. Third-Trimester Bleeding 23. Preterm Labor 24. Premature Rupture of Membranes 25. Intrapartum Fetal Surveillance 26. Postpartum hemorrhage 27. Postpartum Infection 28. Anxiety and Depression 29. Postterm Pregnancy 30. Fetal Growth Abnormalities 31. Obstetric Procedures 32. Contraception and Sterilization 33. Abortion 34. Vulvar and Vaginal Disease 35. Sexually Transmitted Infections & Urinary Tract Infections 36. Pelvic Relaxation & Urinary Incontinence 37. Endometriosis 38. Chronic Pelvic Pain 39. Disorders of the Breasts 40. Gynecological Procedures 41. Puberty 42. Amenorrhea 43. Hirsutism and Virilization 44. Normal and Abnormal Uterine Bleeding 45. Dysmenorrhea 46. Climacteric / Menopause 47. Infertility 48. Premenstrual Syndrome & Premenstrual Dysphoric Disorder 49. Gestational Trophoblastic Neoplasia 50. Vulvar Neoplasms 51. Cervical Disease and Neoplasia 52. Uterine Leiomyomas 53. Endometrial Carcinoma 54. Ovarian Neoplasms 55. Sexuality and Modes of Sexual Expression 56. Sexual Assault 57. Domestic Violence 1. History 2. Examination 3. Pap Smear and Cultures 4. Personal Interaction / Communication Skills 5. Legal Issues / Ethics in Obstetrics & Gynecology 6. Preventive Care and Health Management History This tool is designed to help the teacher lead an interactive session during which the students collectively develop a history taking format they can practice and internalize throughout the rotation. It is geared to taking a complete gynecologic history. Approximate duration: 60 minutes Resources needed: Large blackboard or erasable board vs. 2 to 3 flip charts Suggested curricular timing: First day or week of the rotation Rationale for inclusion in the curriculum: 1. History taking gets little formal curricular attention 2. It is a skill students must have 3. It is a skill that students can actually do, giving them a legitimate role on the health care team and building self-esteem 4. Opportunities to record things in charts is often limited 5. Many institutions have adopted pre-printed history “check-lists” into their formal medical records, encouraging students to become passive “box checkers,” rather than active information gatherers. In attempts to be concise, these forms often are poorly organized and leave little room for the students to record the patient’s actual story. QUESTION 1: What is the first thing that gets recorded in a patient’s history? ANSWER: The chief complaint. QUESTION 2: Outside of prenatal care, why do patients come to see an obstetrician-gynecologist? ANSWER: Going around the room, the students create a list of around 30-40 reasons girls and women seek gynecologic care. It helps set the stage for what they will be expected to learn the rest of the rotation. Their list typically includes: Annual exams Menopause Abnormal Pap smears Infertility Missed periods Pre-conception counseling Heavy periods STD checks Painful periods Vulvar pain Bleeding between periods Vulvar lesions Irregular periods Breast pain Needs contraception Breast masses Contraceptive complaints Postmenopausal bleeding Pelvic Pain Leiomyomata Dysmenorrhea Bartholin’s duct cysts Dyspareunia Pelvic prolapse Vaginal discharge Urinary incontinence Vaginal itching Post-operative care Vaginal odor Wound infections Ovarian cysts Sexual assault QUESTION 3: What comes next in the history? ANSWER: The HPI. Indicate that each item they have listed has its own unique HPI. Describe what you want to hear at the beginning of every HPI, i.e. “The patient is a 26 year old gravida X para Y with a last menstrual period on DATE here today for . . . “ Introduce helpful mnemonics, i.e. “An Alphabet of Pain for the HPI” P = Pain Q = Quality R = Region and radiation S = Severity T = Timing U = Undiagnosed? V = Vomiting and other associated symptoms W = What makes it better /worse OR, the ten “B’s” of the post-partum visit Bladder Bowel Bottom (episiotomy/lacerations) Bleeding (lochia /periods) Breasts Blues Birth control Boinking (OK-not technically acceptable, but it starts with a B) Baby (doing well?) Beaten/battered QUESTION 4: What is the next component of the history during this rotation? Answer: The past ob-gyn history Then present this to the students in the format and order you want them to collect and recorded during the rotation. QUESTION 5: What are the next components of the history that you will need to collect? Answer: Record these on the board in the order you want them collected and presented during the rotation: Past medical history Past surgical history Past psychiatric history Medications Medication allergies Family history Social history QUESTION 6: Small group activity. Break the students into the following four groups: 1. Past medical history 2. Past surgical history 3. Past psychiatric history 4. Family history Each group generates a list of ten common diseases or conditions that they can specifically ask their patients about in their assigned area. When all of the groups are done (5-10 minutes), they report these back to the group as a whole. Teacher records lists on the board. Past Medical History - Lists typically include: Asthma Headaches IBD Allergies SLE GERD Seizure disorders URI’s Hepatitis UTI’s /pyelo Thyroid diseases CVA Hypertension DVT’s/ PE Coagulopathies Diabetes Anemia Hypercholesterolemia From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include associated menstrual abnormalities, symptoms mimicking gynecologic conditions, potentially teratogenic therapies, high-risk pregnancy status, operative risks and impact on birth control decisions. Past Surgical History (non-gynecologic) - Lists typically include: Appendectomy Tooth extractions Tonsillectomy Thyroidectomy Pressure equalization tubes Hernia repair ACL repair Correction of congenital anomalies Breast biopsy Carpal tunnel release Cholecystectomy Plastic surgery From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include anesthetic complications, bleeding abnormalities, blood transfusions and post-operative intra-abdominal adhesions. Past Psychiatric History - Lists typically include: Depression Substance abuse Anorexia Schizophrenia Bulimia Anxiety disorders OC disorder Suicidality Psychosis Post-traumatic stress disorders From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include associated menstrual abnormalities, symptoms mimicking gynecologic conditions, therapy during pregnancy and lactation, birth control options and associations with prior abuse histories. Family History - Lists typically include: Thyroid diseases CVA Hypertension DVT’s /PE Diabetes Inherited anemias Cancers Chromosomal abnormalities Birth defects CAD Coagulopathies Hypercholesterolemia From this list (limit to 10), brainstorm why each disease matters to a practicing ob-gyn. Issues typically include inheritance patterns and impacts on personal health care decision-making. QUESTION 7: What do you routinely include in the social history? ANSWER: Alcohol use Illicit drug use Tobacco use Occupation Family and living situation Exercise Domestic violence If time permits, review the myriad impacts of smoking on reproductive health, i.e. Menstrual irregularity Premature menopause Infertility Miscarriage IUGR PROM PTL/PTD Cervical dysplasia/carcinoma Conclusion: Show the students the template they have collectively developed. Encourage them to practice using it over and over and over again so that it is completely internalized by the end of the rotation.