Rotation 6 OBGYN reflection

Types of patients you found challenging in this rotation and what you learned about dealing with them

I found OB patients to be challenging in this rotation. Their management can be completely different based on their gestational age. They don’t just present for delivery, but also prenatal care and routine checkup during pregnancy. There are also different tests that needed to be order based on trimester. I found that there are no short cuts to learn this. I have learned that the more OB patients I get to see in clinic, in labor and delivery, and during postpartum rounds, the more I will learn to manage based on different stages of the pregnancy. There are also a lot of “numbers” to remember for OBGYN, such as the gestational week for ordering a certain test, the gestational week for different trimester, the blood pressure cut off for confirming different severity of pre-eclampsia, etc. Seeing more OB patients in this rotation is helpful in learning the management based on different gestational age.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

My perspective on diversity has changed as a result of this rotation. I have noticed a lot of Spanish-speaking patients in the hospital where I am doing my rotation. Personally, I do not speak Spanish and I would have to call the interpreter for translation every time I have to interview a Spanish speaking patient. Even though phone interpreter is very convenient and we can have access to it anywhere in the hospital, bad connections can often prevent the interpreters from listening the complete message and they are limited to only what they hear. After seeing a lot of Spanish speaking patients, they motivate me to learn to speak Spanish. I think taking a medical Spanish course in the near future will be beneficial in the hope of serving a larger and diverse community.

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

In this rotation, I have a lot of opportunity to perform pelvic exam including pap smear and vaginal cultural swab. I think it is important to have the proper skill of performing a female genital exam because gyn complaints are very common. Doing a proper gyn exam will aid in the guidance of diagnosis and treatment. Doing pap smear is helpful in screening cervical cancer by identifying abnormal cervical cells, which will lead to early treatment before symptoms even occur. Additionally, endocervical culture will help to identify STDs before it gets complicated into pelvic inflammatory disease and infertility in women. I have also had chances to learn and perform pelvic and transvaginal ultrasounds. These tools are essential in diagnosing life threatening cases like ectopic pregnancy, or to provide care for pregnant patients.

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

In the future rotations, I would like to continue seeking opportunities to complete more hands-on procedures. In order to do this, it will be important for me to stay proactive in this rotation. I will also want to be more prepared prior to the start of the rotation. I will start reading and reviewing the topics before the start of the rotation. This will help me to better adjust and familiarize with different disease.

Rotation 6 OBGYN: Site Evaluation Summary

During the site evaluations, I presented a case on PCOS and infertility. Then I also presented an article related to PCOS. The article concluded that PCOS was associated with non-alcoholic fatty liver disease. I chose to present on PCOS because it was common in women. Untreated PCOS overtime could lead to serious health complications such as diabetes and cancers. After I presented, my site evaluator also went over this topics with me. We discussed about the pathophysiology, clinical manifestation, diagnosis, as well as different management of PCOS. The review was extremely helpful. In addition, I presented my pharm cards. My site evaluator also went over my procedure log book to ensure that I was getting the opportunity to complete different procedures. We also talked about site related questions. She made sure that I was seeing an adequate number and variety of patients every day, that I was having bedside teaching and access to resources.

Article PCOS

Non‐alcoholic fatty liver disease in women with polycystic ovary syndrome: systematic review and meta‐analysis

1. L. Rocha1 · L. C. Faria2 · T. C. M. Guimarães2 · G. V. Moreira1 · A. L. Cândido2 · C. A. Couto2 · F. M. Reis

J Endocrinol Invest 2017

Overview of PCOS:

• It is endocrine syndrome characterized by triad of amenorrhea, obesity, and hirsutism. The main stay of treatment is combination OCPs.

Article Summary:

• The purpose of the study is to assess the association of PCOS with non-alcoholic fatty liver disease. Like PCOS, NAFLD is associated with obesity, DM, insulin resistance, and metabolic syndrome. PCOS women have increased risk of NAFLD, but it is debatable which features of PCOS affect the NAFLD risk.
• Method: 17 studies published between 2007 and 2017 that included 2,734 PCOS patients and 2561 controls of similar age and BMI.
• Results: PCOS patients have increased prevalence of NAFLD (odds ratio 2.54, 95% confidence interval 2.19-2.95). PCOS women with hyperandrogenism have a higher prevalence of NAFLD compared to women with PCOS without hyperandrogenism. The presence of NAFLD is also associated with high serum total testosterone, in addition to obesity and insulin resistance.
• It is important to know about PCOS because it is common in reproductive women. It can lead to health complication if PCOS is untreated. Besides fertility problems, complications include risk for developing insulin resistance, diabetes, abnormal cholesterol/triglyceride level, heart disease, stroke, obesity, and endometrial cancer.

Rotation 6

Identification:

Patient’s name: RM

Age: 25

Gender: Female

Race: Hispanic

Location: Woodhull Hospital, OBGYN clinic

Date: 7/17/19

Informant: self, reliable

CC: “Irregular menses since menarche”

HPI:

25 y/o F G0P0, LMP 2/1/19, with PMHx of constipation presents to the Women’s health clinic with irregular menstruation since menarche. States that she has approximately 3-4 x menstruations in one year, each time last about 3-4 days, medium flow without clots. She has not had a period for more than 5 months. Pt is currently sexually active with one partner, male only, and using condom inconsistently. Further states that she has gained 40-50 lbs in the past 5 months and has difficulty losing weight. Denies hx of STDs, abnormal vaginal discharge, abnormal Pap results, dyspareunia, pelvic pain, urinary symptoms, cold/hot intolerance/palpitation, hirsutism, galactorrhea, N/V, adult acne, facial hairs, significant headache or vision changes.

Differential Diagnosis:

Pregnancy- the first thing I want to rule out for amenorrhea for a woman in childbearing age. Pt is sexually active and using condoms inconsistently

Hypothyroidism- irregular menses and weight gain, hx of constipation.

PMH:

Constipation

Past Surgical History:

None

Medications:

None

Allergies:

NKDA

Family History:

Denies family hx of irregular menstruation, breast cancer, ovarian cancer, and colon cancer.

Social History:

Denies use of EtOH/cigarettes/illicit drugs. Denies exercising and healthy diet.

ROS:

General: Patient denies loss of appetite, generalized weakness, fatigue, fever, chill or night sweats. Admits to recent weight gain of 40-50 lbs in the past 5 months

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool or stool guaiac test or colonoscopy. Admits to constipation.

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Menstrual and Obstetrical: Patient last normal period is 2/1/19, does not remember time of menarche, her menstrual cycle is irregular with medium flow without clots. Patient denies postcoital bleeding, dyspareunia, G0P0000. Last pap smear was 2 years ago, negative for malignancy.

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

General: 25 y.o obese female is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Appears like her stated age.

Vital Signs:

BP (seated): 137/80

HR: 72 BMP, regular

RR:  14, not labored

Temp: 97.5 F oral

O2 sat: 100% room air

Height:5ft 1 weight: 257lbs  BMI: 48.6 obese

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution, no facial hair or chest hair

Nails: not performed

Head: not performed

Eyes: not performed

Ears: not performed

Nose: not performed

Sinuses: not performed

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline. Supple nontender to palpation.

Thyroid: Nontender, no palpable masses, no thyromegaly.

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Breast: Normal contours, no nodules, mass, tenderness, nipple discharge or dimpling.

Abdomen: Flat, symmetrical, no scars, Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness.

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus mobile, non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness

Rectal: not performed

Peripheral vascular: not performed

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve: not performed

Motor/Cerebellar: not performed

Sensory: not performed

Reflexes: not performed

Upper extremities and lower extremities musculoskeletal: Not performed

Imaging and lab works:

Transvaginal ultrasound: pending (patient needs to make an appointment for ultrasound)

Pelvic ultrasound: pending

DHEA sulfate: 152

LH: 11.1

FSH: 5.1

TSH: 1.2

Estrogen level: wnl

Lipid Panel: cholesterol 128, HDL 40, TG 90, LDL 70, cholesterol/HDL ratio 3.2

CMP: wnl

CBC: wnl

Hgb AlC: 6.3

Testesterone, free: 2.4

Testeterone, total: 39.7

Urine pregnancy test: negative

Prolactin: 17

Assessment:

25 y/o female presents with oligomenorrhea, weight gain, and elevated A1C, most likely secondary to PCOS.

Differential Diagnosis:

PCOS: oligomenorrhea, weight gain, and elevated A1C. Will need ultrasound to further assess.

Hypothyroidism- irregular menses and weight gain, hx of constipation. Less likely due to lab shows normal TSH.

Hyperprolactinemia or other hormonal abnormalities- irregular menses, weight gain. Less likely due to normal level of prolactin, normal FH, normal LH, normal testosterone.

Premature ovarian failure: irregular menses, but less likely due to normal levels of hormones

Anatomical problems – irregular menses, but will need ultrasound to further assess.

Plan:

Nutritionist referral

Life style modification – with 10% weight loss over the next 6 months

Advise patient to keep her ultrasound appointment

F/U in 1 month after ultrasound result come back

Patient Education:

Irregular menses can be due to many reasons. We will do lab work to find out what is going on with your menstruation. PCOS is one of the common cause for irregular menses and monthly ovulation is not occurring. It occurs in about 10% of women. Most women with PCOS are obese and insulin resistance. Although PCOS is not completely reversible, there are a number of treatment that can reduce or minimize bothersome symptoms.  Most women with PCOS are able to lead a normal like without significant complications. We will set you up to talk to a nutritionist for diet modification. You are also encouraged to exercise and set up a goal with 10% weight loss over the next 6 months. Make sure that you keep your ultrasound appointment so that we can better help you with your symptoms. You will need to come back in 1 month for a follow up appointment. We will see how you have changed. Oral contraceptives can be used for regulating your menses, but weight loss is one of the most effective approaches for managing insulin abnormalities, irregular menstrual periods, and other symptoms of PCOS.

HP1

OBGYN typhon