Outpatient Gynecology
Case: JoAnna Cunningham, a 40-year-old G4P3 woman, presents to your office complaining of continuous vaginal bleeding for three weeks.
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
Knowledge: BCS Informed Consent, BCS Patient Positioning, BCS Pelvic Examination, BCS Sterile Technique, BCS Surgical Time Out
Basic Clinical Skills:
- Pelvic Examination
- Sterile Technique
- Patient Positioning
- Informed Consent
- Surgical Timeout
- 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
- Demonstrates knowledge of basic abdominal and pelvis anatomy
- Demonstrates basic knowledge of what constitutes normal and abnormal uterine bleeding
- Verbalizes the phases of the normal menstrual cycle
- Demonstrates a basic understanding of patients presenting with a pelvic mass, including differential diagnosis signs and Symptoms
- Recognizes limitations and failures of a team approach (e.g. handoffs, miscommunication) in health care as the leading cause of preventable patient harm
- Demonstrates adequate listening skills
- Communicates effectively in routine clinical situations
- Understands the importance of informed consent
- 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
Develop a differential diagnosis for abnormal uterine bleeding in a reproductive-aged woman
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
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 | |
| Pregnancy | ||
| Polyps | ||
| Adenomyosis | ||
| Leiomyoma | ||
| Endometrial hyperplasia | ||
| Uterine malignancy | ||
| Endometrial atrophy | ||
| Coagulopathy | ||
| Ovulatory dysfunction | ||
| Iatrogenic |
Describe the phases of the menstrual cycle
Milestones: GY 4
Learner Task: Describe the phases of the menstrual cycle.
Educator Checklist: Normal Menstrual Cycle
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 | |
| Menstruation | ||
| Follicular Phase | ||
| LH Surge | ||
| Ovulation | ||
| Luteal Phase |
Obtain a medical history in a reproductive-aged woman
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
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 | |
| Introduces her/himself appropriately (first name, last name, medical student) | ||
| Addresses patient as per patient preference | ||
| Clarifies purpose of visit | ||
| Asks patient if she has concerns other than purpose of visit | ||
| Washes hands correctly (before touching patient) | ||
| Correctly inquires about five or more gynecologic history and sexual history elements: menarche, duration, frequency, first coitus, STIs, abnormal Pap, LMP, sexual orientation, lifetime partners, problems with intercourse, contraception | ||
| Correctly inquires about 3-6 obstetrics history elements: # of pregnancies, # of livebirths, term or preterm, mode of delivery of each, weight of each livebirth, any miscarriages or abortions, more of TOP | ||
| Obtains accurate OPQST of chief complaint. Inquires about three or more elements: 3-6 months heavy periods, three weeks of continuous vb, has not taken any medications, nothing makes it better or worse, heavy clots, changes pad every two hours, has to wear tampons and pads, never happened before | ||
| Obtains accurate ROS questions. Asks at least one question for each potential diagnosis (=7) | ||
| Obtains accurate 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 containing at least three of the following elements: gyn ca, breast ca, colon ca, thyroid dysfunction, coagulopathy | ||
| Obtains accurate social history including at least three of the following elements: smoking, alcohol use, drug use, support system, screen for domestic violence, pets |
Perform a focused physical examination on a reproductive-aged woman
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
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.
| Other | Included =1 | Not Included =0 |
| Asks for at least 2 vital signs | ||
| Performs at least two components: mucous membranes and exopthalmos, palpates thyroid | ||
| General Approach and Communication Skills | ||
| Properly introduces himself or herself to the patient | ||
| Asks patient how she would like to be addressed | ||
| Clarifies purpose of visit | ||
| Washes hands or uses an antiseptic wash | ||
| Uses appropriate draping techniques for patient privacy | ||
| Maintains sterile technique | ||
| Performs the exam in a systematic fashion | ||
| Prefaces exam maneuvers with simple explanations | ||
| Establishes and maintains rapport with the patient | ||
| Makes the patient feel comfortable | ||
| Closes the exam in an appropriate manner | ||
| Gives explanations in clear language, avoids jargon | ||
| Invites questions/ checks for understanding | ||
| External Examination | ||
| Checks all equipment/supplies | ||
| Adjusts exam light prior to gloving and washing hands | ||
| Positions patient on back, hips to end of table and heels on foot rests | ||
| Examines external genitalia | ||
| Inspects mons pubis | ||
| Inspects labia majora | ||
| Inspects labia minora | ||
| Inspects clitoris without touching clitoris | ||
| Inspects urethral meatus | ||
| Inspects introitus | ||
| Inspects Bartholin’s gland | ||
| Inspects perineum | ||
| Inspects anus | ||
| Speculum Examination | ||
| Holds speculum at 45-degree angle |
||
| Inserts speculum properly | ||
| Rotates speculum at full insertion | ||
| Opens speculum slowly | ||
| Identifies cervix | ||
| Secures speculum in open position | ||
| Handles speculum appropriately | ||
| Removes speculum appropriately | ||
| Bimanual Pelvic Examination | ||
| Introduces correct two fingers into vagina with thumbs tucked | ||
| Palpates cervix and cervical os | ||
| Palpates uterine body, apex of fundus | ||
| Notes uterine size | ||
| Describes position of uterus | ||
| Palpates right adnexa/ovary | ||
| Palpates left adnexa/ovary | ||
| Instructs patient to return to sitting position at the conclusion of exam | ||
| Rectovaginal Examination* | ||
| Re-gloves for RV | ||
| Asks patient to bear down as finger is inserted | ||
| Inserts middle finger into rectum | ||
| Inserts index finger into vagina | ||
| Palpates uterus | ||
| Palpates right adnexa/ovary | ||
| Palpates left adnexa/ovary |
*Often not performed – student only asked about technique.
Develop a differential diagnosis for pelvic mass in a reproductive-aged woman
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
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 | ||
| Benign ovarian mass | ||
| Malignant ovarian mass | ||
| Tubo-ovarian abscess | ||
| Hydrosalpynx | ||
| Uterine malignancy | ||
| Leiomyoma |
Order diagnostic tests in a reproductive-aged woman with pelvic mass
EPAs: EPA 3
Learner Task: Order the appropriate diagnostic tests for this patient.
Educator Checklist: Ordering 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 | |
| Pregnancy test/Beta-hCG | ||
| CBC | ||
| TSH | ||
| PT/PTT/INR | ||
| Pelvic ultrasound | ||
| Pap test | ||
| Endometrial biopsy |
Interpret diagnostic tests in a reproductive-aged woman with pelvic mass
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
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 | |
| Anemia: recognizes low Hgb | ||
| Fibroids on ultrasound could be cause of the abnormal bleeding | ||
| Recognizes fibroids |
Perform an evidence-based medicine search on treatment options for abnormal uterine bleeding
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
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 levonorgestrel IUD in abnormal uterine bleeding |
Understand the importance of informed consent
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
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 | |
| Clearly states the procedure for which consent is requested | ||
| Correctly discusses the indication for the procedure | ||
| Correctly states the benefits of the procedure | ||
| Reviews the potential risks of the procedure | ||
| Offers alternatives for the procedure, including no intervention | ||
| Discusses post-procedure expectations | ||
| Clearly introduces self, including role on team | ||
| Establishes rapport with patient | ||
| Uses accessible language and explains medical terminology where appropriate | ||
| Invites patient questions | ||
| Avoids responses implying judgment | ||
| Avoids false reassurances | ||
| Listens without interrupting | ||
| Verifies patient understanding |
Document a clinical encounter in the patient record
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
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 | |
| Explains the purpose of procedure | ||
| Informed consent | ||
| Timeout and patient verification | ||
| Physical examination: writes about at least two of the following: uterine size, position and depth of sound | ||
| Identifies at least two of the following tools utilized: speculum, tenaculum, sound | ||
| How IUD inserted, string cut | ||
| EBL/hemostasis | ||
| Follow-up (precautions, return appointment) |
Communicate effectively with patient and family
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
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.
| Communication: Gathering Information | Included =1 | Not Included =0 |
| Greets patient appropriately, name, role (My name is ______ and I am the third-year medical student on your treatment team) | ||
| Sits down | ||
| Assumes a comfortable interpersonal distance | ||
| Makes eye contact | ||
| Is easily understood, speaks clearly and slowly | ||
| Asks clearly worded and understandable questions, one question at a time | ||
| Asks what the patient already knows about a hysterectomy or what their understanding of the situation is | ||
| Explores the patient perspective by asking: How are you doing with this? How does this make you feel? How is this impacting your life? | ||
| Is well-prepared for the encounter, obtains information in a logical, systematic, orderly progression | ||
| Avoids the use of medical jargon | ||
| Listens attentively, follows patient needs and prompts, does not interrupt | ||
| Asks if the patient or family have questions | ||
| Appears empathic, emotionally supportive to patient, statements of empathy, validates patient concerns, emotions, uses body language | ||
| Communication: Providing Information | Included =1 | Not Included =0 |
| Summarizes information for patient (reviews anemia, uterine size, failure of IUD, explains medical condition: fibroids) | ||
| Provides information about the rationale for recommending hysterectomy | ||
| Provides information on next steps (labs, consent, etc.) | ||
| Provides information on the logistics of hysterectomy (2-3 hour surgery, 2-3 day hospital stay, here is how it is performed, risks, benefits, alternatives) | ||
| Asks for questions, clarifies patient understanding | ||
| Revisits patient agenda (Have we covered everything you wanted to discuss or answered all your questions?) |
Perform a surgical time out
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
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 | |
| 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 |
Demonstrate proper patient positioning for surgery in the low lithotomy position with the arms tucked
Milestones: GY 1a
Learner Task: Demonstrate proper patient positioning for surgery in the low lithotomy position with the arms tucked.
Educator Checklist: Surgical Positioning
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.
| Body | Included =1 | Not Included =0 |
| Positions buttocks at edge of bed, no sacral pressure | ||
| Makes sure patient centered on bed | ||
| Arms | Included =1 | Not Included =0 |
| Makes sure arms are tucked | ||
| Positions arms so they are pronated, thumbs up or thumbs in | ||
| Checks that there is no hyperflexion or hyperextension of elbow | ||
| Checks that there is no hyperflexion or hyperextension of wrist | ||
| Checks that arms are padded | ||
| Checks that fingers are safe | ||
| Legs | Included =1 | Not Included =0 |
| Makes sure that lithotomy leg rest clips at level of the greater trochanter or anterior superior iliac spine | ||
| Positions heels snug in the boot, weight of patient’s leg on the heel, heel at back of boot | ||
| Makes sure that ankle, knee, hip, umbilicus, opposite shoulder all in alignment | ||
| Makes sure there is no pressure on posterior calf | ||
| Makes sure there is no pressure on lateral aspect of leg | ||
| Makes sure there is no hyperflexion or hyperextension of hips | ||
| Makes sure there is no hyperflexion or hyperextension of knees | ||
| Is sure to limit abduction and external rotation |
Perform a surgical scrub, gown and glove using sterile precautions and aseptic technique
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
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 | |
| Removes jewelry | ||
| Correctly places the surgical cap, mask and eye protection | ||
| Correctly opens the packet of surgical scrub soap | ||
| Turns on the water correctly | ||
| Correctly cleans beneath fingernails | ||
| If using surgical scrub brush, scrubs hands and forearms correctly | ||
| Keeps hands and forearms elevated and avoid contamination while entering door to OR | ||
| Accepts the drying towel properly, without contaminating it against his or her body | ||
| Dries hands properly, using a separate sterile area of the towel for each hand | ||
| Properly disposes of the used towel | ||
| Receives and dons the surgical gown properly | ||
| Receives and dons gloves without contaminating gown or gloves | ||
| Turns properly to close off the back of the gown |
Identify elements of pelvic anatomy
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
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 | Included =1 | Not Included =0 |
| Epidermis | ||
| Dermis | ||
| Subcutaneous tissue | ||
| Anterior rectus fascia | ||
| Rectus abdominis muscles | ||
| Posterior rectus fascia | ||
| Pre-peritoneal fat | ||
| Peritoneum | ||
| Arcuate line | ||
| Pelvic Structures | Included =1 | Not Included =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, IP ligament | ||
| Fallopian tube with fimbria | ||
| Ovary | ||
| Uterine-ovarian ligament | ||
| Anterior leaf of broad ligament, bladder flap | ||
| Uterine artery | ||
| Cardinal ligament | ||
| Uterosacral ligament | ||
| Uterus | ||
| Cervix | ||
| Vagina |