NURSING 242-OB-GYN CLINICAL CASES (from APGO site)

NURSING 242-OB-GYN CLINICAL CASES (from APGO site) 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 P