ASSOCIATION OF PROFESSORS OF GYNECOLOGY AND OBSTETRICS

Milestones: GY 1c, GY 2, GY 3, GY 7, IC 2, PB 1, SB 1

EPAs: EPA 1, EPA 13, EPA 2, EPA 3, EPA 7

This case incorporates the following Milestones:

GY 1c: Gynecology Technical Skills: Endoscopy (Laparoscopy, Hysteroscopy, Cystoscopy)

• Demonstrates basic understanding of abdominal and pelvic anatomy
• Positions patient appropriately for surgery

GY 2: Peri-operative Care

• Demonstrates knowledge of basic abdominal and pelvic anatomy

GY 3: Abdominal/Pelvic Pain (Acute and Chronic)

• Demonstrates a basic understanding of patients presenting with abdominal/pelvic pain regarding 1) risk factors; 2) signs and symptoms

GY 7: First Trimester Bleeding

• Demonstrates basic understanding of normal early pregnancy development, including implantation, early embryology, and placental development

SB 1: Patient Safety and Systems Approach to Medical Errors: Participate in identifying system errors and implementing potential systems solutions

• Recognize limitations and failures of a team approach (e.g. hand-offs, miscommunication) in health care as the leading cause of preventable patient harm

PB 1: Self-directed Learning/Critical Appraisal of Medical Literature

• Demonstrates an understanding of critical appraisal of the literature
• Demonstrates responsiveness of constructive feedback

IC 2: Communication with Physicians and Other Health Professionals and Teamwork

• Understands the importance of relationship development, information gathering and sharing and teamwork

This case incorporates the following Entrustable Professional Activities (EPAs):

• EPA 1:   Gather a history and perform a physical examination
• EPA 2:   Prioritize a differential diagnosis following a clinical encounter
• EPA 3:   Recommend and interpret common diagnostic and screening tests
• EPA 7:   Form clinical questions and retrieve evidence to advance patient care
• EPA 13: Identify system failures and contribute to a culture of safety and improvement

EPAs: EPA 1

Learner Task: Take a pertinent history in a reproductive woman.
 
Educator Script: Provide the following pertinent patient history of a reproductive-aged woman with pelvic pain as asked by the learner.

• HPI: Gravida 0, LMP 6 weeks ago
• P GYN Hx: Menarche at 12 years old, menstrual cycles q28-30 days lasting 4 days, moderate dysmenorrhea, no dyspareunia, coitarche at 16 year old, 2 lifetime male partners, treated for chlamydia 1 year ago, using condoms inconsistently for contraception, has never had a Pap smear.
• PMH: None
• Meds: None
• Allergies: No drug allergies
• PSH: Tonsillectomy and adenoidectomy
• Social History: She is in her senior year of high school, makes A’s and B’s in school. She is heterosexual and has had a boyfriend for a little over a year, they use condoms some of the time. She is in the school band, smokes occasionally, has tried alcohol, and denies drugs.
• Review of systems: Complains of loss of appetite today, nausea x 2 weeks, denies the following: vomiting, constipation, increased urinary frequency, vaginal discharge or odor, personal history of bleeding disorders, breast discharge or tenderness, headaches, sob, dizziness, chest pain, and fever.

 
Educator Checklist: History Taking
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
 

Milestones: GY 3

EPAs: EPA 2

Learner Task: Develop a differential diagnosis for abdominal pain.
 
Educator Checklist: Differential Diagnosis of Abdominal Pain in Reproductive Aged Woman
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EPAs: EPA 3

Learner Task: Review the following details of focused physical examination and order the diagnostic tests that are most appropriate next step in management of this patient.

• Vital Signs: BP 110/70, P 101, Respirations 16, afebrile
• General: awake, alert and oriented x 3 in no acute distress
• Heart and lung exam: normal other than tachycardia
• Abdomen: + BS, mildly tender to palpation, guarding, no rebound; no masses appreciated.
• Pelvic: normal external genitalia, normal urethral meatus, moist rugated vaginal mucosa, small amount of blood from cervical os, no discharge or odor appreciated. On bimanual exam, uterus is mildly enlarged and anteverted, smooth outer contour, mild cervical motion tenderness, cervical os is closed, fullness in right adnexa, left adnexa normal.

Educator Checklist: Ordering and Interpretation of Diagnostic Tests
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Milestones: GY 7

EPAs: EPA 2

Learner Task: Review the following lab and radiology results and develop a differential diagnosis for first trimester bleeding.

• Labs: WBC’s normal, Hemoglobin 10.1, Hematocrit 30%, platelets 225K, hCG 8326 mIU/ml, Blood type O Positive
• Radiology: Ultrasound showed right sided adnexal mass containing a gestational sac measuring 0.9 cm with yolk sac measuring 0.4 mm. No fetal pole or heart beat. The entire adnexal mass measures 2.2 cm, with mild free fluid in pelvis; no intrauterine gestational sac seen. Normal left adnexa.

 
Educator Checklist: Differential Diagnosis of First Trimester Bleeding
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Learner Follow-up: Based on the information so far, what is the diagnosis?
 
Correct Answer: Unruptured ectopic pregnancy
 

Milestones: GY 3

Learner Task: List the risk factors for ectopic pregnancy and which factors this patient has.
 
Educator Checklist: Risk Factors for Ectopic Pregnancy (*this patient has)
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Milestones: PB 1

EPAs: EPA 7

Learner Task: Perform a quick literature search for potential treatments and describe management options for ectopic pregnancy.
 
Educator Checklist: Management of Ectopic Pregnancy
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Milestones: SB 1

EPAs: EPA 13

Learner Task: Communicate elements of sign-out/handoff using SBAR in a patient with suspected pregnancy.
 
Educator Checklist: Communication Elements of Sign-Out/Handoff
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Milestones: SB 1

EPAs: EPA 13

Learner Task: After completing your brief literature search, the nurse calls and says the patient just returned from ultrasound is having increased abdominal pain. Her vital signs are now: BP 80/60, P 125, afebrile, RR 24. The student re-evaluates the patient who now has rebound and guarding on abdominal exam. The student calls the chief resident to give sign-out of the patient. Describe the value and limitations of patient handoffs.

Educator Checklist: Values and Limitations of Patient Handoffs
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Milestones: GY 1c

Leaner Task: You are now in the operating room. You plan to do a laparoscopy. The patient has been given general endotracheal anesthesia. Demonstrate proper patient positioning of laparoscopy.
 
Educator Checklist: Patient Positioning for Laparoscopy
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Milestones: GY 1a, GY 2, GY 4, GY 5, IC 1, IC 3, SB 1

EPAs: EPA 1, EPA 11, EPA 13, EPA 2, EPA 3, EPA 5, EPA 7

This case incorporates the following Milestones:

GY 1a: Patient Care, Gynecology Technical Skills: Laparotomy

• Demonstrates knowledge of basic abdominal and pelvic anatomy
• Demonstrates basic surgical principles including use of universal precautions and aseptic technique
• Positions patient appropriately for surgery

GY 2: Medical Knowledge, Peri-operative Care

• Demonstrates knowledge of basic abdominal and pelvis anatomy

GY 4: Medical Knowledge, Abnormal Uterine Bleeding (Acute and Chronic)

• Demonstrates basic knowledge of what constitutes normal and abnormal uterine bleeding
• Verbalizes the phases of the normal menstrual cycle

GY 5: Medical Knowledge, Pelvic Mass

• Demonstrates a basic understanding of patients presenting with a pelvic mass, including differential diagnosis signs and Symptoms

SB 1: Systems-based Practice: Patient Safety and Systems Approach to Medical Errors: Participate in Identifying System Errors and Implementing Potential Systems Solutions

• Recognizes limitations and failures of a team approach (e.g. handoffs, miscommunication) in health care as the leading cause of preventable patient harm

IC 1:  Interpersonal and Communication Skills: Communication with Patients and Families

• Demonstrates adequate listening skills
• Communicates effectively in routine clinical situations

IC 3: Interpersonal Communication Skills: Informed Consent and Shared Decision Making

• Understands the importance of informed consent

This case incorporates the following Entrustable Professional Activities (EPAs):

• EPA 1:  Gather a history and perform a physical examination
• EPA 2:  Prioritize a differential diagnosis following a clinical encounter
• EPA 3:  Recommend and interpret common diagnostic and screening tests
• EPA 5:  Document a clinical encounter in the patient record
• EPA 7:  Form clinical questions and retrieve evidence to advance patient care
• EPA 11:  Obtain informed consent for tests and/or procedures
• EPA 13:  Identify system failures and contribute to a culture of safety and improvement

Milestones: OB 2, OB 4, OB 5, PB 2, PR 1

EPAs: EPA 1, EPA 4, EPA 7

This case incorporates the following Milestones:

OB 2: Care of Patients in the Intrapartum Period

• Demonstrates knowledge of routine uncomplicated Intrapartum care including normal labor

OB 4: Obstetrical Technical Skills

• Demonstrates basic surgical principles, including use of universal precautions and aseptic technique
• Performs basic procedures, including speculum examination and cervical examination

OB 5: Immediate Care of the Newborn

• Performs initial warming and drying of a non-depressed infant

PB 2: Quality Improvement Process:  Systematically analyze practice using QI methods and implement changes with the goal of practice improvement

• Has a commitment to self-evaluation, lifelong learning, and patient safety

PR 1: Compassion, Integrity, and Respect for Others

• Understands the importance of compassion, integrity, and respect for others
• Demonstrates sensitivity and responsiveness to patients

This case incorporates the following Entrustable Professional Activities (EPAs):

• EPA 1: Gather a patient history and perform a physical examination
• EPA 4: Enter and discuss orders and prescriptions
• EPA 7: Form clinical questions and retrieve evidence to advance patient care
• EPA 10: Recognize a patient requiring urgent / emergent care and initiate evaluation and management
• EPA 12: Perform general procedures of a physician

This case incorporates the following Milestones:

OB 1: Antepartum Care and Complications of Pregnancy

• Demonstrates basic knowledge of normal obstetrical care and common medical complications seen in pregnancy

OB 3:  Care of Patients in the Postpartum Period

• Demonstrates basic knowledge of normal postpartum care

OP 1:  Family Planning

• Verbalizes basic knowledge about common contraceptive options

This case incorporates the following Entrustable Professional Activities (EPAs):

• EPA 1: Gather a history and perform a physical examination
• EPA 2: Prioritize a differential diagnosis following a clinical encounter
• EPA 3: Recommend and interpret common diagnostic and screening tests
• EPA 4: Enter and discuss orders and prescriptions
• EPA 10: Recognize a patient requiring urgent or emergent care

This case incorporates the following Basic Clinical Skills (BCS) checklists: N/A

This case incorporates the following Milestones:

OP 2: Ambulatory Gynecology

• Demonstrates basic knowledge about common ambulatory gynecologic problems

OP 3: Care of the Patient with Non-reproductive Medical Disorders

• Demonstrates and understanding of common non-reproductive medical disorders

OP 4: Healthcare maintenance and disease prevention

• Demonstrates knowledge of the characteristics of a good screening test
• Demonstrates knowledge of indications and limitations of commonly used screening tests

SB 2: Cost-Effective Care and Patient Advocacy

• Understands the importance of providing cost-effective care
• Understands the role of physicians in advocating for appropriate women’s healthcare

PB 1: Self-directed learning/critical appraisal of medical literature

• Demonstrates an understanding of critical appraisal of the literature
• Demonstrates responsiveness to constructive feedback

This case incorporates the following Entrustable Professional Activities (EPAs):

• EPA 1: Gather a history and perform a physical exam
• EPA 2: Prioritize a differential diagnosis following a clinical encounter
• EPA 3: Recommend and interpret common diagnostic and screening tests.
• EPA 4: Enter and discuss orders and prescriptions
• EPA 7: Form clinical questions and retrieve evidence to advance patient care

Milestones: IC 2, SB 1

EPAs: EPA 13

Learner Task: Perform a surgical time out.
 
Educator Checklist: Surgical Time Out
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Milestones: GY 1c, GY 2

Learner Task: Describe surgical anatomy for a laparoscopy.
 
Educator Checklist: Abdominal Wall and Pelvic Anatomy
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Milestones: IC 2

Educator Feedback: Provide the learner with feedback on any elements where he or she can improve.
 
Learner Task: Demonstrate responsiveness to constructive feedback.
 
Educator Checklist: Responsiveness to Feedback by Learner
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Milestones: OB 1

EPAs: EPA 1

Learner Task: Obtain a complete history from this patient.
 
Educator Script: Provide the following patient history as asked by the learner:

• HPI: She is feeling well and experiences positive fetal movement. Her pregnancy was complicated by advanced maternal age, grand multiparity, obesity, and diet controlled gestational diabetes.
• PMH: HTN (no meds); AMA; obesity (pre-pregnancy height/weight was 64”/207 pounds)
• PSH: none
• P Ob Hx: 5 vaginal deliveries; 1 preterm due to hypertension; 1 spontaneous abortion
• P Gyn Hx: no abnormal Pap tests; last Pap test 2 years ago; no sexually transmitted diseases; no endometriosis/fibroids; monthly menstrual cycles lasting 5 days
• Medicines: none
• Allergies: none
• SH: no tobacco; no alcohol; married
• FH: non-contributory
• Review of systems: fatigued; no bleeding since delivery; denies skin changes/hair changes; no depression; no vaginal bleeding; no regular contractions; denies headaches, visual changes, epigastric pain; minimal symmetric lower extremity edema.

 
Educator Checklist: HPI
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Milestones: OB 1

EPAs: EPA 1

Learner Task: Perform a focused physical exam on this patient.
 
Educator Script: Provide the following details of focused physical examination as asked by the learner:

• Vitals: temperature 98.6° F; BP 149/96; HR 86; RR 18; oxygen saturation 97%
• Height: 64 inches
• Weight: 207 pounds
• Skin: warm, dry; no rashes; no lesions.
• Abdomen: no right upper quadrant tenderness; fundus soft, midline, non-tender; fundal height 31 cm.
• Extremity exam: 3+ deep tendon reflexes, 1 beat clonus, 1+ pitting edema to mid-calf, symmetric
• Vagina: no abnormal discharge; cervix 2 cm dilated/50% effaced, soft, mid position; sutures palpable; fetal head at -2 station; no evidence of ruptured membranes
• Fetal heart tones: 140 bpm baseline; moderate variability; + accelerations; no decelerations; Category I

 
Educator Checklist: Physical Examination

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Milestones: OB 1

EPAs: EPA 2

Learner Task: Develop an initial problem list.
 
Educator Checklist: Patient Problem List
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Milestones: OB 1

EPAs: EPA 3, EPA 4

Learner Task: The nurse asks what tests you would like to order for the patient. Order the appropriate diagnostic tests.
 
Educator Checklist: Diagnostic Tests
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Milestones: OB 1

EPAs: EPA 10

Learner Task: Identify additional problems found in the patient based on the diagnostic test results.
 
Educator Script: Provide the following diagnostic tests results to the learner (if ordered in the previous task):
 

Educator Checklist: Interpret Diagnostic Tests
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EPAs: EPA 10, EPA 2

Learner Task: What is the diagnosis for this patient?
 
Correct Diagnosis: Pre-eclampsia with severe features

Milestones: OB 1

EPAs: EPA 10

Learner Task: Identify risk factors for pre-eclampsia.
 
Educator Checklist: Risk Factors for Pre-Eclampsia
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Milestones: OB 1

Learner Task: Develop a management plan for a patient with pre-eclampsia with severe features.
 
Educator Checklist: Management of Pre-Eclampsia with Severe Features
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Milestones: OB 3, OP 1

Learner Task: The patient ultimately delivers vaginally and returns for postpartum examination. Identify the components of her postpartum care that are important to address at the postpartum visit.
 
Educator Checklist: Postpartum Care of Patient with Pre-Eclampsia
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Milestones: OP 2

EPAs: EPA 2

Learner Task: Develop a differential diagnosis for vaginal discharge in a reproductive-aged woman.
 
Educator Checklist: Differential Diagnosis for Vaginal Discharge
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EPAs: EPA 1

Learner Task: Take a complete history from the patient.
 
Educator Script: Provide the following patient history as asked by the learner:

• HPI: She reports three episodes of vulvovaginal itching, with thick white vaginal discharge. She denies any odor to the discharge. Episodes started about two weeks ago. She has tried over the counter products, which help but do not completely eliminate the symptoms. She is not currently sexually active.
• PMH: None
• PSH: None
• POB History: 2 NSVDs, both pregnancies complicated by diet controlled gestational diabetes.
• Allergies: None
• Medications: None
• SH: Non-smoker, divorced. Works in billing at the hospital.
• FH: diabetes, no malignancies
• P Ob Hx: Last Pap test three years ago, no abnormal Pap tests. No sexually transmitted infections. History of five lifetime sexual partners, and has been sexually active with men.

Educator Checklist: HPI

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EPAs: EPA 1

Learner Task: Perform a physical examination of a reproductive-aged woman.
 
Educator Script: Provide the following information as asked by the learner:

• Vital signs: BMI 37, HR 80, BP 120/60, Temperature 98.4° F

 
Educator Notes and Diagrams: Breast Examination

• Learners should:
  • Wash their hands with soap and warm water or alcohol-based antiseptic.
  • Learners should inform the patient that they are performing a breast exam. This is a good time to ask the patient if they have noticed any lumps or other problems with their breasts.
  • Be organized and have the patient properly draped, i.e. cover areas not being examined.
• Inspection:
  • Asking the patient to lower the gown, learners should visually inspect the breasts from front and sides.
  • Learners should look for size, symmetry (some variation is normal), shape, contour (flattening, masses, and dimpling), skin (color, edema, rashes, thickening, and venous pattern), and scars (previous surgery, injuries).
  • Learners should do the inspection with the patient performing arm maneuvers: overhead (#1), waist (#2), and leaning forward (#3). Learners are looking for any retraction when the patient is leaning forward, or contracting the pectoral muscles.

• Palpation
  • Lymph nodes
    • Cervical nodes: These nodes are found along the sides of the neck.
    • Axillary nodes: The patient is in a seated position using appropriate draping technique. With patient’s arm at their side and the examiner lifting the arm away from side to access nodes (#4).
    • Supraclavicular nodes: These nodes are found along a line immediately above the clavicle. This is done by learners stepping around behind the patient.

• Bimanual palpation while patient sitting
  • Learners should perform bimanual palpation with the patient in a seated position, using appropriate draping technique.
  • Learners should use the right hand above/left hand below to palpate the right breast. Learners should use the pads of the fingertips to compress the breast tissue between fingertips. Using this technique, learners can check for consistency, nodules, masses, and tenderness, which might not be felt in supine breast exam. Repeat for left side by standing on patients’ left side and reversing hands (left on top, right on bottom).
  • Complete breasts palpation while patient is supine
    • Learners should pull out the footrest, and ask the patient to put their arm overhead during supine palpation. The arm overhead helps to stretch the breast tissue against the chest wall.
    • Learners should then perform a complete palpation of the breasts. Learners should use the flat part of the fingers (and a rotary motion) against the chest wall using a radial or spiral pattern without missing areas, compressing the breast tissue against the chest wall in all quadrants of the breast (#5). Learners should be noting tissue consistency, elasticity, nodules, indurations, masses, and tenderness.

• Learners should palpate all of the breast, which continues up the chest wall to the clavicle (collar bone) and towards the axilla (armpit).
• Learners should inspect and palpate the nipples (#6), looking for size, shape, inversion, rashes, ulceration, discharge, scaling, crusting, elasticity, retraction, areolar edema and masses. Learners should gently grasp and compress the nipple and areolar tissue between thumb and index finger, noting the color consistency and quantity of any discharge (#7).

 
Educator Checklist: Breast Examination 
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Educator Notes and Diagrams: Pelvic Examination

• Learners should:
  • Select the appropriate sized speculum, warm speculum and test speculum on patient’s leg for comfortable temperature.
  • Inform patient prior to speculum insertion.
  • Insert speculum at 45-degree downward angle, then rotate and open when completely inserted.
  • Visualize the cervix by adjusting the speculum anteriorly or posteriorly.
  • Use the appropriate collection vial with the correct attached swab for each culture
  • For Chlamydia and Gonorrhea cervical collection, insert the swab into the endocervix for approximately 10 seconds (insert only superficially in pregnancy)
  • For vaginal cultures, obtain a specimen from the posterior fornix
  • Insert the swab into the vial, break off the excess swab and cap off the collection vial/tube securely and label the specimen
  • Traditional Slide Cytology Collection
    • Learners should use the spatula clover leaf end to collect ectocervical cells, or spatula end for vaginal cuff cells, and then smear them in a thin layer on the slide.
    • On the same slide, learners should smear endocervical cells collected using a cytobrush. Only insert cytobrush superficially in pregnancy.
    • The learner or assistant should spray the slide with cytology fixative immediately after cytology collection and place it in the appropriate container.
    • The learner or assistant should label the container appropriately.
  • Liquid-Based Cytology Collection
    • Learner should first use the plastic (not wood) spatula to collect ectocervical cells (rotate 360 degrees), then brush-like device (rotate 180 degrees) to collect endocervical cells.
    • Both spatula and brush should be swept around the inside of the liquid-based cytology specimen collection container 10 times to loosen the maximum number of cervical cells into solution.
    • The learner or assistant should label the container appropriately.

 
Educator Checklist: Cervical Cytology
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Milestones: OP 2, OP 3

EPAs: EPA 2, EPA 3

Learner Task: The physical exam demonstrates a normal breast exam, erythema of the vaginal epithelium with thick white curd-like discharge. Otherwise her pelvic examination was normal. A photograph of the wet prep is below. Describe the active issues for this patient.
 

Photo courtesy of Hope Haefner, MD, University of Michigan
 
Educator Checklist: Active Issues Found in Physical Examination
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Milestones: OP 2, OP 3

EPAs: EPA 2, EPA 3, EPA 4

Learner Task: Describe the treatment plan for each active issue in this patient.
 
Educator Checklist: Treatment Plan
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Milestones: OP 4, PB 1, SB 2

EPAs: EPA 3, EPA 7

Learner Task: The patient informs you that her insurance will pay for the mammogram, and asks for evidence to support your recommendation. List one resource you would utilize to find mammogram screening recommendations?
 
Educator Checklist: Mammogram Screening Guidelines
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Milestones: OP 4

EPAs: EPA 3

Learner Task: List the important principles of a screening test.
 
Educator Checklist: Principles of a Screening Test
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Source:  Principles and Practices of Screening for Disease. World Health Organization.
 

Milestones: PB 1, SB 2

EPAs: EPA 3, EPA 7

Learner Task: Counsel the patient about why you are not recommending a mammogram at this time.
 
Educator Checklist: Counsel Patient about Unnecessary Mammogram
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Milestones: OB 2

EPAs: EPA 7

Learner Task: Develop a differential diagnosis for abdominal pain in a pregnant woman.
 
Educator Checklist: Differential Diagnosis for Abdominal Pain in a Pregnant Woman
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Milestones: OB 2

EPAs: EPA 1

Learner Task: Obtain a medical history in a pregnant woman with abdominal pain.
 
Educator Script: Provide the following pertinent patient history of a pregnant woman with abdominal pain as asked by the learner:

• HPI:  Gravida 2, Para 1, 38 weeks plus 3 days by LMP and US dating. Patient is in town for her sister’s wedding and noticed leakage of clear fluid 4 hours ago. Patient complains of non-radiating lower abdominal pain that began 2 hours ago. Pain is intermittent, every 4-5 minutes, each episode lasting for 30 seconds. Nothing makes the pain better or worse. +FM, No VB. Denies nausea, vomiting, pain/burning on urination. Patient is a non-smoker, denies hx of drug abuse or trauma.
• PMH:  None
• PSH:  None
• Meds: Prenatal Vitamins
• Allergies: Penicillin>anaphylaxis
• P Ob Hx: NSVD-female infant weighing 6 pounds, 12 oz. She was in labor for 36 hours and pushed for 3 hours. Baby spent one week in NICU for GBS infection.
• Prenatal Labs: O+, antibody negative, RPR-NR, Rubella Immune, Hep B Surface antigen negative, HIV negative, GC negative, Hemoglobin electrophoresis AA, CF screen negative, Pap test negative for malignancy, 50 gm Oral Glucose Challenge Test 115, GBS+.
• First and second trimester ultrasound: Unremarkable, c/w LMP.
• P Gyn Hx: Menarche at age 13, menstrual cycles q28-30 days lasting 4-6 days, denies dysmenorrhea or dyspareunia, coitarche at age 17, 5 lifetime male partners, denies history of sexually transmitted infections or abnormal Pap test.

Educator Checklist: HPI
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Educator Checklist: History Taking
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Milestones: OB 4

EPAs: EPA 1, EPA 12

Learner Task: Perform a focused physical examination on a pregnant woman with abdominal pain.
 
Educator Script: Provide the following details of focused physical examination as asked by the learner:

• Vital Signs: BP 124/84, P 101, Resp 22, afebrile, EFW 3200 grams
• General: awake, alert and oriented x3 in moderate distress with contractions
• Heart: Nl S1 S2, RRR, no murmurs, rubs or gallops
• Lungs: bilaterally CTA, no wheezes, rales, or rhonchi
• Abdomen: +BS, gravid, fundal height 36, non-tender to palpation, no guarding, no rebound
• Speculum: no blood, +pooling, +nitrazine
• Pelvic: vulva/vagina: normal external genitalia
• Cervix: 4/50/0/vertex, wet mount performed
• Extremities: no clubbing, cyanosis, or edema
• Microscopic examination of vaginal fluid shows:

Educator Checklist: Physical Examination
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Educator Checklist: Intrapartum Examination
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Milestones: OB 2

Learner Task: The attending is finishing a procedure in another room and asks if there is anything concerning about the fetal heart rate tracing pictured below. Report the fetal heart rate findings and discuss fetal heart rate features which could be concerning.
 
Fetal Monitoring Strip

 
Educator Checklist: Fetal Heart Rate Tracing
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EPAs: EPA 10, EPA 12, EPA 4

Learner Task: The nurse asks for the plan and orders for Ms. Mary Smith. Develop an appropriate treatment plan and write orders.
 
Educator Checklist: Treatment Plan/Order
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Milestones: PR 1

Learner Task: Two hours later, the patient is asking questions as to how long her labor will be and what she should expect this time. She appears anxious and is concerned regarding prior GBS-affected baby. Address the patient’s concerns/issues.
 
Educator Checklist: Professionalism
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Milestones: PB 2

Learner Task: The cross-covering nurse has the IV bag labeled with penicillin for Jane Smith. She asks is it okay to administer the antibiotic to your patient Jane Smith for her GBS+ status. Address this nursing concern.
 
Educator Checklist: Patient Safety
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Milestones: OB 2

Learner Task: Discuss the patient’s labor progress, stages of labor and the cardinal movements of labor, and any future labor management actions with the attending.
 
Educator Checklist: Labor
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Milestones: OB 4, OB 5

EPAs: EPA 10, EPA 12

Learner Task: Two hours after admission, the patient is found to be 7 cm dilated and requests an epidural. The patient receives an epidural. Two hours later the nurse calls you because your patient is complaining about pressure. Patient is FD/100% effaced/+1 station. Discuss future management of labor.
 
Educator Checklist: Delivery
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Educator Checklist: Neonatal Warming and Drying of Non-Depressed Infant
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Milestones: GY 4

EPAs: EPA 2

Learner Task: Develop a differential diagnosis for abnormal uterine bleeding in a reproductive-aged woman.
 
Educator Checklist: Differential Diagnosis of Abnormal Uterine Bleeding in a Reproductive-Aged Woman
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Milestones: GY 4

Learner Task: Describe the phases of the menstrual cycle.
 
Educator Checklist: Normal Menstrual Cycle
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Milestones: GY 4

EPAs: EPA 1

Learner Task: Take a complete history from this patient.
 
Educator Script: Provide the following pertinent patient history of a reproductive-aged woman with abnormal uterine bleeding as asked by the learner:

• HPI: A 40-year-old G4P3 woman presents to your office complaining of heavy menstrual periods over past 3-6 months, and now this last period has lasted for three weeks. She denies cramps and pelvic pain. She is unsure if she has of fibroids; she has not been told she has them.
• PMH:  None
• PSH:  D&C 15 years ago
• Meds: None
• Allergies: No known drug allergies
• P OB Hx: 3 term NSVD’s, uncomplicated, 7-8 pounds each; no miscarriages; one abortion at 10 weeks via D&C; no history of post-partum hemorrhage
• P GYN Hx: 12/28/3-5 days, still regular cycles, but periods now lasts 7-10 days; age at first intercourse =17; number of lifetime partners=3, all men; current partner=1 for past 12 years; no history of abnormal Pap tests, last pap was >5 years ago; no history of STI’s; no difficulties with intercourse; not using any contraception
• Social Hx: Denies tobacco, ETOH, IVDA
• Review of Systems: She complains of weight gain of 5-8 pounds in past three months, feels more tired than usual, denies nausea, vomiting, constipation, weight loss, change in appetite, no personal history of bleeding disorders, denies breast discharge or tenderness, no headaches, no change in vision, no dry skin, no hair growth in abnormal places, no shortness of breath, no dizziness, no chest pain, no bleeding gums, no nose bleeds, no easy bruising

 
Educator Checklist: History Taking

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Milestones: GY 4

EPAs: EPA 1

Learner Task: Perform a focused physical examination on a reproductive-aged woman.
 
Educator Script: Provide the following details of focused physical examination as asked by the learner:

• Vital Signs: 37.5°C, BP 122/68 mm Hg, BMI 33 kg/m²
• HEENT: Examination shows pale mucous membranes. She has no exophthalmos and her thyroid is symmetric, slightly enlarged, non-tender.
• Pelvic examination: No vulvar, vaginal or cervical lesions. You palpate an enlarged, midline pelvic mass, approximately 16 weeks in size. It is non-tender with irregular contour. You do not think there are any adnexal masses, but are unsure. There are no hemorrhoids present. 
  

 
Educator Checklist: Physical Examination

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*Often not performed – student only asked about technique.

Milestones: GY 5

EPAs: EPA 2

Learner Task: Develop a differential diagnosis for pelvic mass in a reproductive-aged woman.
 
Educator Checklist: Differential Diagnosis of Patient Presenting with Pelvic Mass

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EPAs: EPA 3

Learner Task: Order the appropriate diagnostic tests for this patient.
 
Educator Checklist: Ordering Diagnostic Tests
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EPAs: EPA 3

Learner Task: Interpret the diagnostic test results below. What additional problems have you identified with the patient based on these labs?

• Pap test is negative for malignancy and HPV negative
• Pelvic ultrasound reveals a fibroid uterus with multiple intramural and subserosal fibroids, largest 5x4cm, with an endometrial stripe of 10 mm and normal adnexa
• Hemoglobin: 9.2 g/dL
• Platelets: 223,000/uL
• Serum Beta-hCG: <5 mIU/mL (<5mIU/mL)
• Serum TSH: 4 mIU/mL (0.4-5 mIU/L)
• PT: 12 sec (11-14 nl range)
• PTT: 30 sec (25-35 nl range)
• INR: 1.0 (0.8-1.2 nl range)
• Endometrial Biopsy: proliferative endometrium, no hyperplasia

 
Educator Checklist: Problem List
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EPAs: EPA 7

Learner Task: Perform a quick literature search on the effectiveness of treating abnormal uterine bleeding with a levonorgestrel intrauterine device.
 
Educator Checklist: Management of Abnormal Uterine Bleeding
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Milestones: IC 3

EPAs: EPA 11

Learner Task: You decide with the patient to treat her abnormal uterine bleeding with a levonorgestrel intrauterine device. Consent the patient for an IUD placement.
 
Educator Checklist: IUD Informed Consent
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EPAs: EPA 5

Learner Task: Write a procedure note for the IUD insertion.
 
Educator Reference: See sample procedure note and follow up below:

• Procedure Note: Patient desires long-term, reversible contraception. Informed consent was obtained. Timeout procedure was performed to ensure correct patient and correct IUD. A bimanual exam was performed to determine the position of the uterus. The speculum was placed. The vagina and cervix was sterilized in the usual manner and sterile technique was maintained throughout the course of the procedure. A single toothed tenaculum was applied to the anterior lip of the cervix and gentle traction applied to straighten and stabilize it. The depth of the uterus was sounded to be of appropriate depth (usually 6.5 to 8.5 cm). With gentle traction on the tenaculum, the IUD was inserted to the appropriate depth and deposited by withdrawing on the insertion tube holding the rod steady. The string was cut to an estimated 4 cm length. Bleeding was minimal. Hemostasis achieved. The patient tolerated the procedure well without complications.
• Follow-up: Standard post-procedure care was explained and return instructions were given.

 
Educator Checklist: IUD Procedure Note
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Milestones: IC 1

Learner Task: Three weeks later the patient presents to the emergency department with acute vaginal bleeding. Your colleague tells you the following patient history, physical exam findings and laboratory results when you arrive in the emergency department:

• The patient presented to the ER one hour prior. This patient is known to the Gyn service. She has documented uterine fibroids on US and had a Levonorgesterel IUD placed three weeks ago. She reports soaking through 2-3 large pads per hour for the past five hours. She reports dizziness, lightheadedness, and fatigue. She last ate four hours prior. She denies nausea and vomiting. She denies pain. She has not had intercourse since the IUD insertion. She denies trauma. She denies fever.
• Physical exam: 110/60, 83bpm, 18, 36C
• Gen: pale, comfortable. Tired appearing
• HEENT: dry mucous membranes
• Heart: regular, mild tachycardia
• Lungs: CTA bilaterally
• Abdomen: palpable mass to 2 cm below umbilicus.  Midline, mobile, nontender. No rebound or guarding.
• Groin: negative
• Pelvic: normal vulva, vagina and cervix. Clot in vagina. Active bleeding viewed from cervical os.
• Bimanual exam: no CMT; uterus enlarged to 16-week size with irregular contour
• Lab: Hg 6.2, PT/PTT/INR normal, Beta-hCG is negative, type and screen drawn, chem-7 normal

You call your attending and present this patient. You and the attending decide to send the patient to the floor for stabilization, with plan for hysterectomy once this is achieved. Communicate to the patient and her family the plan to send the patient to the floor for stabilization, and then hysterectomy once stabilization achieved.

 
Educator Checklist: Interpersonal and Communication Skills and Professionalism
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EPAs: EPA 13

Learner Task: Consent is obtained from the patient for surgery. Day of surgery has arrived and you are in the operating room with the patient. She has not yet received anesthesia. Perform a surgical time out according to the World Health Organization Surgical Safety Checklist.
 
Educator Checklist: WHO Surgical Safety
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Milestones: GY 1a

Learner Task: Demonstrate proper patient positioning for surgery in the low lithotomy position with the arms tucked.
 
Educator Checklist: Surgical Positioning
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Milestones: GY 1a

EPAs: EPA 13

Learner Task: You will be assisting the surgeon during this case. Perform a surgical scrub, gown and glove using sterile precautions and aseptic technique.
 
Educator Checklist: Scrubbing/Gowning/Gloving
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Milestones: GY 1a

Learner Task: You are now operating and viewing the patient’s pelvic anatomy. Identify elements of pelvic anatomy.*
 
*Educator Note: An abdominal hysterectomy module (found on ACOG website>CREOG section>Surgical Curriculum in Obstetrics and Gynecology>Abdominal Hysterectomy) may be used for this portion of the module.
 
Educator Checklist: Abdominal Wall and Pelvic Anatomy
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