Inpatient Gynecology
Case: A 17-year-old white female presents to the emergency department with vaginal bleeding and right-sided pelvic pain beginning three hours ago and getting progressively worse.
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
Knowledge: Abnormal Uterine Bleeding
Basic Clinical Skills:
- Patient Positioning Checklist
- Surgical Timeout Checklist
- Demonstrates basic understanding of abdominal and pelvic anatomy
- Positions patient appropriately for surgery
- Demonstrates knowledge of basic abdominal and pelvic anatomy
- Demonstrates a basic understanding of patients presenting with abdominal/pelvic pain regarding 1) risk factors; 2) signs and symptoms
- Demonstrates basic understanding of normal early pregnancy development, including implantation, early embryology, and placental development
- Recognize limitations and failures of a team approach (e.g. hand-offs, miscommunication) in health care as the leading cause of preventable patient harm
- Demonstrates an understanding of critical appraisal of the literature
- Demonstrates responsiveness of constructive feedback
- Understands the importance of relationship development, information gathering and sharing and teamwork
- 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
Obtain a medical history in a reproductive-aged woman
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.
| Included =1 | Not Included =0 | |
| Student introduced her/himself appropriately (first name, last name, medical student) | ||
| Student addressed patient as per patient preference | ||
| Student clarified purpose of visit | ||
| Student washed hands correctly (before touching patient) | ||
| Obtains accurate gynecologic history and sexual history | ||
| Obtains accurate obstetrics history | ||
| Obtains accurate review of systems for chief complaint |
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| Obtains accurate past medical history | ||
| Obtains accurate surgical history | ||
| Obtains accurate medication use, asks about over the counter and herbal supplements | ||
| Obtains accurate allergy history | ||
| Obtains accurate family history | ||
| Obtains accurate social history including smoking, alcohol use, drug use |
Develop a differential diagnosis for abdominal pain in a reproductive-aged woman
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
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.
| Included =1 | Not Included =0 | |
| Intrauterine pregnancy | ||
| Ectopic pregnancy | ||
| Spontaneous abortion (missed, threatened, incomplete, complete, septic) | ||
| Appendicitis | ||
| Ovarian cyst | ||
| Pelvic inflammatory disease | ||
| Ovarian torsion |
Order and interpret diagnostic tests for a reproductive-aged woman with abdominal pain
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
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.
| Included =1 | Not included =0 | |
| Orders pregnancy test | ||
| Orders CBC | ||
| Orders blood type and Rh screen | ||
| Orders pelvic ultrasound |
Develop a differential diagnosis in a patient with first trimester bleeding
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
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.
| Included =1 | Not included =0 | |
| Intrauterine pregnancy | ||
| Ectopic pregnancy | ||
| Spontaneous abortion (missed, threatened, incomplete, complete, septic) | ||
| Bleeding from lower urogenital tract (i.e. cervix, vagina) | ||
| Molar pregnancy | ||
| Bleeding from rectum |
Learner Follow-up: Based on the information so far, what is the diagnosis?
Correct Answer: Unruptured ectopic pregnancy
List risk factors for 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)
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.
| Included =1 | Not included =0 | |
| Maternal age 35-44 years | ||
| Previous ectopic pregnancy | ||
| Previous pelvic or abdominal | ||
| History of gonorrhea | ||
| History of pelvic inflammatory | ||
| Several induced abortions | ||
| Conceiving after tubal ligation | ||
| Conceiving while an IUD is in place | ||
| Smoking* | ||
| Endometriosis | ||
| Using fertility medications |
Perform an evidence-based medicine search on treatment options for ectopic pregnancy
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
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.
| Included =1 | Not included =0 | |
| Provides evidence for medical treatment | ||
| Provides evidence for surgical treatment options |
Communicate elements of sign-out/handoff using SBAR in a patient with suspected pregnancy
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
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.
| Included =1 | Not included =0 | |
| Situation (pertinent history and physical): unstable ectopic pregnancy in the ER. Student gives chief complaint, estimated gestational age, hCG level, US report, vital signs, exam, change in symptoms | ||
| Background: mentions all elements: age, history of chlamydia, vaginal bleeding | ||
| Assessment: unstable ectopic pregnancy | ||
| Recommendation: emergent operation |
Describe the value and limitations of patient handoffs
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
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.
| Handoff Value | Included =1 | Not included =0 |
| Team-approach to care | ||
| Takes advantage of hierarchal knowledge and experience of upper level residents/faculty | ||
| Allows for clarification of medical issues | ||
| Accurate and timely transition of patient care information | ||
| Handoff Limitations | Included =1 | Not included =0 |
| Interferes with continuity of care | ||
| Doesn’t always prioritize highest acuity patients or care elements | ||
| Not all information may be appropriately communicated |
Demonstrate proper patient positioning of laparoscopy
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
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.
| KNOWLEDGE | |||
| General | Included =1 | Not included =0 | |
| Describes the most common positions for patients in routine gynecologic procedures. | |||
| Describes the goal of patient positioning for surgery | |||
| Describes the risks if surgical positioning is done incorrectly | |||
| Describes the appropriate steps in patient positioning in surgery | |||
| Lateral aspect of knee | Included =1 | Not included =0 | |
| Nerve at risk (common peroneal) | |||
| Consequence of injury (decreased sensation on lateral lower leg, dorsal foot, foot drop) | |||
| Correct position to avoid injury (knee toward opposite shoulder, no pressure on lateral aspect) | |||
| Elbow | Included =1 | Not included =0 | |
| Nerve at risk (ulnar) | |||
| Consequence of injury (decreased sensation and weakness in 4th and 5th digits) | |||
| Correct position to avoid injury (elbow padded, arm pronated, avoid hyperextension) | |||
| Hip | Included =1 | Not included =0 | |
| Nerve at risk (femoral and lateral femoral cutaneous) | |||
| Consequence of injury (sensory deficit of thigh, weakness of hip flexion, knee extension) | |||
| Correct position to avoid injury (no hyperflexion of hip, limit abduction and external rotation) | |||
| SKILLS | |||
| Body | Included =1 | Not included =0 | |
| Buttocks at edge of bed, no sacral pressure | |||
| Patient centered on bed | |||
| Accurately assesses cervical effacement | |||
| Arms | Included =1 | Not included =0 | |
| Arms tucked | |||
| Arms pronated, thumbs up or thumbs in | |||
| No hyperflexion or hyperextension of elbow | |||
| No hyperflexion or hyperextension of wrist | |||
| Arms padded | |||
| Fingers safe | |||
| Legs | Included =1 | Not included =0 | |
| Lithotomy stirrup clips at level of the greater trochanter or ASIS | |||
| Heels snug in the boot, weight of patient on the heel, heel at back of boot | |||
| Ankle, knee, hip, umbilicus, opposite shoulder all in alignment | |||
| No pressure on posterior calf | |||
| No pressure on lateral aspect of leg | |||
| No hyperflexion or hyperextension of hips | |||
| No hyperflexion or hyperextension of knees | |||
| Limit abduction and external rotation | |||
Perform a surgical time out
Milestones: IC 2, SB 1
EPAs: EPA 13
Learner Task: Perform a surgical time out.
Educator Checklist: Surgical Time Out
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.
| Included =1 | Not included =0 | |
| Definition and purpose | ||
| Describes the purpose of the surgical safety checklist | ||
| Identifies the three times that the surgical safety checklist is utilized during a surgical case | ||
| Performance of the pre-incision surgical safety checklist | ||
| Confirms that all team members have been introduced by name and role | ||
| Confirms the patient’s identity, surgical site and procedure | ||
| Reviews anticipated critical events (critical steps, operative duration and anticipated blood loss) | ||
| Confirms with anesthesia staff any concerns specific to the patient | ||
| Confirms with nursing staff: A) sterility of OR, B) equipment availability and C) other concerns | ||
| Confirms that appropriate choice of prophylactic antibiotics and time of administration have been given prior to incision or that they are not indicated | ||
| Confirms that all essential imaging results for the correct patient are displayed in the room |
Describe surgical anatomy for a laparoscopy
Milestones: GY 1c, GY 2
Learner Task: Describe surgical anatomy for a laparoscopy.
Educator Checklist: Abdominal Wall and Pelvic Anatomy
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.
| Abdominal Wall | Correctly identified =1 | Not identified =0 |
| Epidermis | ||
| Dermis | ||
| Subcutaneous tissue | ||
| Anterior rectus fascia | ||
| Rectus abdominis muscles | ||
| Posterior rectus fascia | ||
| Pre-peritoneal fat | ||
| Peritoneum | ||
| Arcuate line | ||
| Pelvic Structures | Correctly identified =1 | Not identified =0 |
| Round ligament | ||
| Posterior leaf of the broad ligament | ||
| Ureter | ||
| External Iliac artery and vein | ||
| Ovarian artery and vein, infundibulo-pelvic ligament, suspensory ligament of the ovary | ||
| Fallopian tube with fimbria | ||
| Ovary | ||
| Uterine-ovarian ligament | ||
| Anterior leaf of broad ligament, bladder flap | ||
| Uterine artery | ||
| Cardinal ligament | ||
| Uterosacral ligament | ||
| Uterus | ||
| Cervix | ||
| Vagina |
Demonstrates responsiveness to constructive feedback
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
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.
| Demonstrated =1 | Not Demonstrated =0 | |
| Learner listens carefully to the feedback without interrupting | ||
| Uses open body language | ||
| Learner asks clarifying questions | ||
| Learner follows up with educator where appropriate |