Ambulatory Clerkship Roles and Responsibilities

Clerkship student Roles in Clinic:

• Orange team:                                                         YACC4      8:30a/1p
  This clinic is unique for clerkship students as the patients are all coming to clinic to see you as their primary provider. Most are gyn patients with urgent care issues. The goal of this experience is to familiarize you with your new role as a primary care giver: taking a history, performing the exam, and coming up with a plan for testing and treatment.
  
• Continuity clinic :                                         YACC 4 or DOB 8:30a/1p
  Each of you will have 5 or 6 clinics with one of our Attending staff or Senior residents. The goal of the experience is to both allow you to participate in the care of Ob and Gyn patients (generally you will review the charts, go in to see the patient, take an interval history, do an Ob "belly check" and present the patient to her MD), as well as allow you to develop a relationship with an attending who will watch your development and progression during your clerkship.
  
• Specialty Clinics: MFM, Colposcopy, Urogynecology, Gyn Oncology, Reproductive Endocrine, U/S, and Genetics :
  
  During your clerkship you will each go to one of each of the above clinics (though only one of Urogyn, REI or Onc). Your role in these clinics is generally as active observer, though in MFM you should function as you do in your continuity clinic. You should read ahead of time about the clinic issues managed in these clinics. Be sure to read the additional Orientation information on the Family Planning unit and the FCC prior to your 1st visit.
  
• Maternal Fetal Medicine Clinic Schedule
  Monday p: Focus on Sickle Cell Disease, Seizure disorders, Thyroid Disorders
  Tuesday a: Substance abuse in pregnancy clinic
  Thursday a: HIV Pregnancy clinic
  Thursday p: Pregnancy after Loss, Thrombophilias, Multiple Gestations
  Thursday p: Pregnancy after Loss, Thrombophilias, Multiple Gestations
  Friday a: Diabetes and Pregnancy
  

Family Planning:

This portion of your rotation is divided into three segments: The family planning clinic, the pre-procedural unit and the gynecological procedure unit. Contraception and unwanted pregnancy are very private and sometime emotional subjects for our patients. We expect all students to be respectful of decisions made by our patients. We invite all students to discuss any questions or emotions they may experience during their rotation with any faculty in the division.

• Family Planning
• During this portion of your rotation you will be working with our Family Planning nurse practitioners. Your experience here will expose you to contraceptive options and management. You will be able to participate in IUD insertions and checks. Patients also have Implanon insertions and pregnancy testing with options counseling.
  
• Pre-procedure unit
• This clinical session involves options counseling and work up for unwanted pregnancies. We offer outpatient procedures ranging from early medical terminations (using mifepristone and/or misoprostol) to early surgical terminations (using manual vacuum aspiration) to late surgical terminations (using electric suction and sometimes other technologies such as ultrasound or special instruments). Terminations at later gestations are sometimes initiated in the outpatient clinic with digoxin which is injected into the amniotic sac the day before admission. Transvaginal and limited abdominal ultrasound done in this unit help teach how gestational age correlates with sonographic findings. Students will have the opportunity to do routine GYN exams and STI testing.
  
• Gynecologic procedure Unit
• This is where surgical terminations of pregnancies are done. Staff will ask each patient if they will allow you to observe the procedure. Bear in mind that this is a stressful event in the lives of our patients and that some of them will decline to have an observer. Once you are in the procedure room you will see that the provider first does a pelvic exam to confirm the uterine anatomy, and then sets up instruments. Graduated dilators are introduced to dilate the cervix in proportion to the gestational age. A clear plastic cannula is then attached either to a syringe for early (manual vacuum) surgical procedures or to a hose for later (electric) procedures. Students are invited to observe procedures up to 13 completed weeks. Observing D&Es done on larger gestations are limited to fourth year elective students, but arrangements can be made for students in their third year to observe later gestations if special requests are initiated by the student.
  
  After the procedure you will move to the dirty utility room. Save your questions for the privacy of this little space where you will examine the products of conception. This step is sometimes graphic but enables the student to get the opportunity to learn more about embryonic and fetal development and is essential in the care of our patients.
  

Clerkship Student Responsibilities in Clinic:

• Professionalism:
• You are expected to be on time and appropriately dressed (no scrubs in clinic). Your nametag should be easily visible at collar level. People want to call you by name, but are likely not to remember it at first, make it easy for us!
  
• Preparation:
• You should have read about the specialty clinics you in which you are participating, and prior to your first clinic review information about taking an Ob/Gyn history (covered in Orientation), and the pelvic examination (reviewed in Orientation).
  
• Documentation:
• You are expected to be responsible for completing the charting on the patients that you have seen WITHIN 24 hours (NO EXCEPTIONS), you should forward the note to the Attending to sign. Charts should be completed in the format on Logician, you should sign and date all notes.

History Taking in Obstetrics and Gynecology
Derived and Modified from TEACHING TOOLS-APGO Medical Student Objectives Eighth Edition

Chief Complaint.

Annual exams	Menopause
Abnormal Pap smears	Infertility
Missed periods	Pre-conception counseling
Heavy periods	STD checks
Painful periods	Vulvar pain Vulvar lesions
Bleeding between periods
Irregular periods	Breast pain Breast masses Postmenopausal bleeding Leiomyomata
Needs contraception
Contraceptive complaints
Pelvic Pain
Dysmenorrhea	Bartholin's duct cysts Pelvic prolapse Urinary incontinence
Dyspareunia
Vaginal discharge
Vaginal itching	Post-operative care Wound infections Sexual assault
Vaginal odor
Ovarian cysts
Prenatal care

 

HPI

“The patient is a 26 year old gravida X para Y with a last menstrual period on DATE here today for . . . “

Term= greater than or equal to 37 weeks
Preterm= less than 37 weeks, spontaneous loss greater than or equal to 20 weeks
Abortions=spontaneous or induced prior to 20 weeks
Living= all offspring currently alive

“An Alphabet of Pain for the HPI”

P = Pain
Q = Quality
R = Region and radiation
S = Severity
T = Timing
U = Undiagnosed?
V = Vomiting and other associated symptoms
W = What makes it better /worse

The ten “B's” of the post-partum visit

Bladder
Bowel
Bottom (episiotomy/lacerations)
Bleeding (lochia /periods)
Breasts
Blues
Birth control
Boinking (OK-not technically acceptable, but it starts with a B)
Baby (doing well?)
Beaten/battered

Preventative heath screening specific to women.

Cervical cytology
Annual exam
Screening and diagnostic breast studies
Colon screening
Sexually transmitted disease screening
Bone density screening

Past OB/Gyn History
Past Menstrual history

Onset of menses
Cycle length and recent changes
Days of bleeding and recent changes
Character of bleeding (light, mod., heavy pad or tampon use) recent changes
Symptoms with menses-mood, acnes, breast tenderness, pain

Past Gynecologic history

Abnormal pap smears, treatment and follow up
Sexually Transmitted Infections, treatment and outbreak frequency if HSV
Contraception use past and present
Protection against Sexually Transmitted Infections

Past Obstetrical history

Number of pregnancies
Outcomes of pregnancies
Complications in pregnancy
Delivery modes
Complications of delivery
Postpartum complications

Sexual History

Are you sexually active?
If so with whom? (this allows identification of the number and gender of partners)
With men or women? (if not answered clearly above)
How many lifetime partners have you had? (try to emphasize risk is conferred by behavior with partners not only number of partners and therefore the merit of this question is dependant on behaviors and protection against STIs)
Are you comfortable with your sexual relationship?
Are you having any difficulties or discomfort in your sexual relationship?
Are you satisfied with your sexual relationship?
Do you feel safe in your sexual relationship?

Past Medical History

Past Surgical History

Past Psychiatric History

Medications/Allergies

Family History

Social History

Assessment/Management Plan

Problem list

Differential diagnosis

Management

Laboratory tests and other studies

Treatment

Education

Continuing plan of care

Obstacles to care

Patient's response to plan