I was placed in Woodhull Hospital for my OB/GYN rotation for 5 weeks. There I saw a diverse population and solidified my GYN exam skills. I also had an opportunity to learn the management of patients in labor and their postpartum care. Here are some artifacts from my rotation.

 

 1. History and Physical Write up 

Taiba Shah

OB/GYN Rotation #1 (Clinic) –H&P

 

C/C: “My vagina feels itchy” x 3 weeks

 

HPI: F.M. is a 63 y/o F G3P3003, 3 NSVD, LMP: 10/31/1998 c/o vaginal itch x 3 weeks. The pts states the pruritus started in the beginning of December and has gradually increased over the past few weeks. It is constant and not alleviated or aggravated by anything. She is not sexually active and denies history of STIs. She reports that she has not changed any soaps, detergents, or recently used antibiotics. She is on a new chemotherapy medication for Esophageal cancer but states that the symptoms started before starting the drug. Pt denies vaginal odor, discharge, pain, dysuria, vaginal bleeding, fever, chills, chest pain, SOB.

 

ROS:

Gen – Denies fever, chills, night sweats, and weight change

Pulm – Denies SOB, cough

CV – Denies chest pains, palpitations,

 

OB: G3P3003, 3NSVD

Gynecological: Admits to menopause at 42 y.o. vaginal dryness and pruritis and grade 2 uterine prolapse. Denies vaginal bleeding, vaginal discharge, pelvic pain, rectal bleeding, dysuria, hesitancy, urgency, incontinence, abnormal, breast mass, breast discharge. Admits to self-breast exams. Last mammogram 11/22/2019- normal, pap smear 8/15/2018- normal, no hx of abnormal pap smears. Denies h/o STIs or PID, Denies h/o fibroids or ovarian cysts.

 

PMHx:

Current medical conditions – Squamous cell carcinoma of the esophagus, COPD, diverticulosis, hypothyroidism, GERD, grade 2 uterine prolapse,

Past Medical Conditions – Denies past medical history

PSHx – Esophageal surgery 11/2016- no complications

Current medications –Pembrolizumab 200- mg IV x1 in 21-day cycle for esophageal neoplasm, Ondansetron 8 mg PO q8h x2 doses 30 mins before and 1-2 days after chemo for chemotherapy induced nausea and vomiting, Levothyroxine 88 PO mcg qd for acquired hypothyroidism,

Pantoprazole 40mg PO qd x 4-8 weeks for erosive esophagitis

Allergies – NKDA, denies environmental and food allergies

Family hx – Denies history of breast, ovarian and endometrial ca

Social hx – Former smoker. Denies alcohol/illicit drug use. Single and denies being sexually active

DDx: 

1. Estrogen Deficiency
2. Vulvar lichen sclerosus
3. Lichen planus
4. Vulvar cancer

VS: T 98.6F, HR 88 bpm, BP 102/65 Rt arm sitting, RR 19, SpO2 100%, BMI 16

PE:

Gen – Alert & oriented. No acute distress. Cachectic

Abd –Soft, non-tender, non-distended

GU – No rashes, warts, normal Bartholin gland, dry vaginal mucosa with atrophy, no discharge,

Vulva patches of depigmentation and white papules on labia minora. Stage 2 uterine prolapse. Cervical os without discharge. Loss of folds between labia minora and majora making them almost indistinguishable.

Labs/Procedures:

No labs/Procedures. 

Refined DDx:

1. Vulvar lichen sclerosus
2. Estrogen Deficiency
3. Vulvar cancer 

Assessment: 63 y/o F w/ h/o squamous cell carcinoma of the esophagus, COPD, diverticulosis, hypothyroidism, GERD, grade 2 uterine prolapse, G3P30031 LMP: 10/31/1998 c/o vaginal itch x 3 weeks, presentation is most consistent with vulvar lichen sclerosus.

Plan:

1. Vulvar lichen sclerosus
   1. Clobetasol 0.05% cream 1 application 2 times a day for 3 weeks and then taper to 2 times per week on week 4, apply a thin layer on the external labia
   2. Explanation of dermatological changes that have occurred on the vulva. Also due to the patient’s cancer history, a close follow up will be required to determine response to the steroids and rule out vulvar cancer.
   3. F/u in 1 month for a possible biopsy

2. Stage 2 prolapse:
   1. Asymptomatic, continue expectant management.
3. Pap due 8/2021. Informed the patient that her next Pap will be her last one.

2. Article and Summary 

Link: Aticle-Halonen_et_al-2017-International_Journal_of_Cancer

The purpose of this study was to estimate the risk of different malignancies among women who were previously diagnosed with lichen sclerosus. There has been an association with vulvar LS leading to vulvar squamous cell carcinoma and the risk is 5%. This was a prospective cohort study that identified 7,616 women diagnosed with vulvar LS from 1970-2012. The follow-up periods were <1 year, from 1 to <5 years and 5 years or more. Most of the LS patients were postmenopausal. A total of 812 cancers were found among the women with LS. The risk was higher during the first year of follow up. Women in their 30’s had the highest incidence of vulvar cancer and women over 80 had the lowest. There was also an increase in vaginal cancer, a decrease in cervical cancer, and no increase in uterine or ovarian cancer. The study concluded that patients diagnosed with LS had a significantly elevated risk of developing vulvar cancer.

3. Site evaluation presentation summary 

I had two site evaluations. I presented the case above for my first site evaluation. My evaluator stated that it was an interesting case but he asked would I have done anything different in the management of the patient. I stated I would have taken a biopsy during the visit due to the patient’s cancer history, and smoking history, vulvar cancer is very likely. I learned that for my future H&Ps to write my plan instead of the plan from the provider I was working with. In my first visit, I realized that I didn’t do a good job memorizing my pharm cards and I mixed up the information for two similar-sounding drugs. In my last site visit, I made sure that I knew all the information on all my pharm cards. I presented my article well and received positive feedback. My last site evaluation went better than the first since I applied what I wanted to change from my first visit to my last visit.

4. Typhon 

Link: Typhon Totals

5. Self-Reflection

Exposure to new techniques or treatment strategies 

My OB/GYN tremendously helped me become comfortable with sensitive exams. In the first two weeks of my rotation, I was in the clinic. There I had many opportunities to get hands-on experience with different GYN exams and observe procedures. The first time I did a speculum exam I was unable to locate the cervix. I eventually learned some techniques for locating the cervix like aiming the speculum more posterior or changing the speculum size if the cervix is deeper. One other interesting method I was taught was for more anterior cervices, I saw a PA flip the speculum so the handle was up and there was a better visualization of the cervix.

One procedure I was proud of doing was removing an IUD. It was easier than I expected. With the supervision of a physician, I used sterile equipment and visualized the IUD string and removed it with loop forceps. The patient did not indicate any discomfort. Some procedures I observed were implant removal and insertion, Depo Provera shots administration, and endometrial biopsies.

Interpersonal changes and how you addressed them 

Some interpersonal challenges that I encountered are some providers and nurses don’t really pay mind to students. I found that if I was present, engaged, and asked questions they would teach me or let me do procedures. One provider had me shadow them most of the day but at one point I asked if I could do the next Pap smear and she said sure, the rest of the day she supervised me while I did all the pelvic exams. I also was initially nervous that patients would not want a student to be in their delivery room, or do exams but a vast majority of patients had no problem with students. I just had to make sure I asked permission to stay in the room and made it clear that it was 100% their decision.

Managing new patients and the challenges that arise from that 

There are some patients who would come in upset for a variety of reasons. I learned that if you let a patient speak about what is troubling them without interrupting but just listening to them is most beneficial. Most of the time they want their frustrations to be heard, and sometimes they express pertinent information that can impact their management,

What do you want to improve on for the following rotations? What is your action plan to accomplish that? 

Since this was my first rotation, I have nothing to compare it to however I learned a lot about how to be proactive during rotations to get the most out of it. For example, during my labor and delivery week I was on-call, however, I stayed on the floor most of the shift. This is how I was able to assist with cervical ballooning, observe many deliveries and scrub into a handful of c-sections. I learned the importance of introducing myself to everyone especially the nurses. I wish I did more hands-on tasks in labor and delivery. In the future, I would like to have more courage to ask the nurses if I could do procedures like inserting an IV or blood draw, while they supervise me. Also, I would like to take better notes for a smoother flow when I present patients. I plan on doing this by using a template to ensure I don’t miss anything and stay organized.

This rotation helped me get comfortable doing a physical exam I struggled with during the didactic year. I also learned how to take notes on postpartum, GYN, and labor and delivery patients. I am not sure what field I will be working in but at this point, I am interested in Emergency Medicine and I am sure that I will be utilizing the skills I gained from this rotation to my future practice.