Office Practice / Outpatient Gynecology
Case: Monica Jones is a 29-year-old woman who presents to the gynecology clinic for a health maintenance examination. Your medical assistant reports that the patient would like to discuss her vaginal discharge. In addition, she is interested in a referral for a baseline screening mammogram because a colleague at work was recently diagnosed with breast cancer.
Basic Clinical Skills:
- Breast Examination
- Pelvic Examination
- Cervical Cytology
- Demonstrates basic knowledge about common ambulatory gynecologic problems
- Demonstrates and understanding of common non-reproductive medical disorders
- Demonstrates knowledge of the characteristics of a good screening test
- Demonstrates knowledge of indications and limitations of commonly used screening tests
- Understands the importance of providing cost-effective care
- Understands the role of physicians in advocating for appropriate women’s healthcare
- Demonstrates an understanding of critical appraisal of the literature
- Demonstrates responsiveness to constructive feedback
- 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
Develop a differential diagnosis for vaginal discharge in a reproductive-aged woman
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
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 | |
| Normal physiologic discharge | ||
| Yeast vaginitis | ||
| Bacterial vaginosis | ||
| Trichomonas | ||
| Gonorrhea/chlamydia | ||
| Cervical or uterine malignancy |
Obtain a medical history in a reproductive-aged woman
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
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 | |
| Appearance of discharge | ||
| Frequency of episodes | ||
| Odor | ||
| Duration of symptoms | ||
| Any new sexual partners | ||
| Assessment of risk factors (diabetes, use of antibiotics) | ||
| PMH: including vaccinations | ||
| P Ob Hx: including prior pregnancies, pregnancy complications, gestational diabetes | ||
| P Gyn Hx: including abnormal Pap tests, last menstrual period, use of hormonal contraception | ||
| FH: including malignancies | ||
| SH: including tobacco, drugs, alcohol, intimate partner violence, abuse | ||
| Medications |
Perform a physical examination of a reproductive-aged woman
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.
- Lymph nodes
- 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
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 | |
| Washed hands or used an antiseptic wash | ||
| Used appropriate draping techniques | ||
| Performed the exam in an organized fashion | ||
| Closed the exam in an appropriate manner | ||
| With patient sitting, inspected both breasts from front and sides | ||
| Asked patient to put arms overhead | ||
| Asked patient to put arms on her waist and press elbows forward | ||
| Asked patient to lean forward with arms out in front | ||
| With patient sitting, palpated the cervical, supraclavicular and axillary lymph node | ||
| With patient sitting, performed bimanual palpation of the breast | ||
| In the supine position, asked patient to put arms overhead | ||
| Performed complete palpation of the breast with the flat part of the fingers | ||
| Performed palpation of the axillary tail | ||
| Gently palpated and expressed nipples |
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
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.
| Cervical Cytology Collection | Included =1 | Not Included =0 |
| Selected appropriate sized speculum and warmed it | ||
| Inserted the speculum correctly and visualized the cervix | ||
| Collected the cervical cells correctly using spatula and cytobrush to the pelvic curve | ||
| Used correct technique to collect cells into the vial | ||
| Labeled the specimen appropriately | ||
| Cervical/Vaginal Culture and Wet Prep Collection | ||
| Selected appropriate sized speculum and warmed it | ||
| Inserted the speculum correctly and visualized the cervix | ||
| Used the appropriate collection vial for the specimen | ||
| For a cervical culture, placed the swab in the endocervix for 10 seconds | ||
| For a vaginal culture, obtained specimen from the posterior vaginal fornix | ||
| Capped off and labeled specimen appropriately | ||
| Prepared slide for wet prep correctly | ||
| Correctly identified yeast, clue cells, trichomonas, squamous cells and white blood cells, if present | ||
| Appropriately discussed findings and treatment with supervising clinician |
Identify the active issues for this patient based on physical examination
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
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 | |
| Vaginal discharge | ||
| Obesity/history of GDM | ||
| Request for mammogram |
Develop a treatment plan for active issues in a patient
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
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 | |
| Vaginal discharge: prescribes correct antifungal therapy | ||
| Obesity/history of GDM: orders HgA1c, fasting or 2-hour glucose tolerance test (gtt), counsels about weight loss | ||
| Request for mammogram: counsels patient that she does not need screening mammogram at this time |
Utilize national screening guidelines and recommendations to advance patient care
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
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 | |
| Learner can cite any of these national screening guidelines (examples include ACOG, US Preventative Task Force Recommendation, NCI) |
Identify important principles of a screening test
Milestones: OP 4
EPAs: EPA 3
Learner Task: List the important principles of a screening test.
Educator Checklist: Principles of a Screening Test
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 | |
| The condition should be an important health problem | ||
| There should be a recognizable latent or early symptomatic stage | ||
| The natural history of the condition, including development from latent to declared disease, should be adequately understood | ||
| There should be an accepted treatment for patients with recognized disease | ||
| There should be a suitable test or examination that has a high level of accuracy | ||
| The test should be acceptable to the population | ||
| Facilities for diagnosis and treatment should be available | ||
| The cost of screening (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole, and screening should be a continuing process and not a ‘once and for all’ project | ||
| There should be an agreed policy on whom to treat as patients |
Source: Principles and Practices of Screening for Disease. World Health Organization.
Advocate for appropriate women’s health care
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
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 | |
| Use patient centered language | ||
| Discusses recommended age of mammogram screening onset (40, 45 or 50 acceptable depending on cited guideline) | ||
| Discussed low risk of breast cancer for women <40 | ||
| Discussed low risk due to negative family history | ||
| Discusses risks of false positives for women <40 | ||
| Offers annual clinical breast exam |