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4/18/2018

4/18/2018. S t e p U p T o R esidency [o f fice p r actice]. Objecti v es Enhance kn o wled g e o f o f fice based Ob/ G yn p r actice t h r ough a simula t ed patie n t c ase P r actice skills y ou will use early on during o f fic e base d e ncoun t e r s

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4/18/2018

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  1. 4/18/2018 Step Up ToResidency [officepractice] • Objectives • EnhanceknowledgeofofficebasedOb/Gyn practicethroughasimulatedpatientcase • Practiceskillsyouwilluseearlyonduringofficebasedencounters • Discussself‐directedlearningandcritical appraisalofmedicalliterature • Understandtheimportanceofcommunicationwithpatients,familyandothermembersof thehealthcareteam • MilestonesinOfficePractice • Demonstratesbasicknowledgeaboutwhatconstitutesnormalandabnormaluterinebleeding • Verbalizesthephasesofthenormalmenstrual cycle • Verbalizesbasicknowledgeaboutcommoncontraceptiveoptions • Demonstratesbasicknowledgeaboutcommonambulatorygynecologicproblems

  2. 4/18/2018 • MilestonesinOfficePractice • Demonstratesanunderstandingofcommon non‐reproductivemedicaldisorders • Demonstratesknowledgeofthe characteristicsofagoodscreeningtest • Demonstratesknowledgeofindicationsand limitationsofcommonlyusedscreeningtests • Demonstratesanunderstandingofcritical appraisaloftheliterature • MilestonesinOfficePractice • Demonstratesadequatelisteningskills • Communicateseffectivelyinroutineclinicalsituations • Understandstheimportanceofrelationshipdevelopment,informationgatheringandsharing • Understandstheimportanceofinformedconsent • OfficePracticeCaseSimulation • A46yearoldG4P3013presentstoyourofficewithacomplaintofheavyvaginalbleedingfor thepast3weeks.

  3. 4/18/2018 Whatarekeyelementsinthehistory? • Whatarekeyelementsinthehistory? • FullgynhistoryincludingSTIsandpaphistory • Detailsaboutmenstrualhistoryandcurrent bleedingpattern/associatedpain • PMH/PSH • Currentmedications • Currentcontraceptionorfertilitydesires • Targetedfamilyhistory • Smokinghistory • ReviewofSystems • OfficePracticeCaseSimulation • Gynhistory • menarcheage11/mensesmonthly/7‐10days • NoSTIs,inmonogamousrelationshipfor15years • Lastpap5yearsagoandwasnormal • Mammogram6monthsago‐normal • Bleedinghistory • Heavyx6months • Increaseddysmenorrhea • PMH • none • PSH • D&Catage30foramissedabortion

  4. 4/18/2018 • OfficePracticeCaseSimulation • Medications • multivitamin • Contraception • Condomsbutwouldliketodiscussotheroptions • Familyhistory • Coloncancer:m.grandmother • HTN:father • Socialhistory • Notobaccouse,1drink/weekETOH,nodruguse • ROS • 10lbweightgainin1yr • Increasedfatiguefor2mo Reviewofmenstrualcycle

  5. 4/18/2018 • Hormonaleffectsonendometrium • Estrogenisthefertilizer • Allowsendometrialproliferation • Progesteroneisthelawnmower • Keepsliningthin Whatarekeyelementsinthephysical? • Whatarekeyelementsinthephysical? • Vitalsigns • Thyroidexam • Abdominalexam • Pelvicexam • Papsmear • Endometrialbiopsy • Considergonorrhea/chlamydiatesting

  6. 4/18/2018 • OfficePracticeCaseSimulation • HandsonExercise: • Performapelvicexam(externalexam,speculumexam,bimanualexamandcollectionofpap) • FacultywillreviewkeypointandPearlsrelatedtothepelvicexam • Reviewofcervicalcancerscreening • Beginscreeningatage21 • Screenevery3yearsages21‐29 • Screenevery5yearsforages30andoverifpapand HPVtestingcombined,ifpapalonethenevery3years • WomenwithhistoryofCIN2or3shouldreceivescreeningforatleast20years • Maystopscreeningatage65iflast3papsnormalandnoabnormalpapsinpast10years • Maystopscreeningifhysterectomyhasbeendoneforbenignindicationsandnopriorhistoryofhighgrade cervicaldysplasia • HumanPapillomaVirus • DNAviruses • Lowoncogenic • Highoncogenic(16and18responsiblefor70%cervicalcancerinUS) • MostTransient • 50%cleared8mo • 90%cleared2yr • Infectsimmaturebasalcellsat squamocolumnarjunction

  7. 4/18/2018 • AbnormalCervicalCytology (Age25andover) • AtypicalSquamousCellsofUndetermined Significance(ASC‐US) HPVneg HPVpos • Repeatpap3yrCOLPOSCOPY • LowGradeSquamousIntraepithelialLesion(LSIL)COLPOSCOPY • HighGradeSquamousIntraepithelialLesion(HSIL)COLPOSCOPY • AbnormalCervicalCytology (Age21‐24) • AtypicalSquamousCellsofUndeterminedSignificance(ASC‐US) HPVneg HPVposorunknown(preferred) • Repeatpap3yrRepeatpap1yr • LowGradeSquamousIntraepithelialLesion(LSIL)repeatpap1yr • HighGradeSquamousIntraepithelialLesion(HSIL)COLPOSCOPY • PrinciplesofaScreeningTest • Identifiesaclinicallysignificantdiseasethathasapreclinicalstate • Resultsinsignificantmorbidityormortalityifleftuntreated • Atreatmentmustexist • Testisreasonablypriced • Testisnoninvasive

  8. 4/18/2018 • PrinciplesofaScreeningTest • Testissensitive • Correctlyidentifiespatientswiththedisease • Testisspecific • Correctlyidentifiespatientswithoutthedisease Reviewoftheendometrialbiopsy AbnormalUterineBleeding(AUB) Indicationforendometrialbiopsy >45yo • <45yo • unopposedestrogen (obesity/PCOS) • failedmedicalmgmt • persistentAUB DiagnosisofAUBinReproductive‐AgedWomen,ACOGPracticeBulletin128 • OfficePracticeCaseSimulation • YourfacultyfacilitatorwillreviewkeypointandPearlsrelatedtoperformingan endometrialbiopsy • Performendometrialbiopsysimulation

  9. 4/18/2018 • OfficePracticeCaseSimulation • Vitals • –Temp37.4,BP122/74,BMI28kg/m2,pulse72 • Urinepregnancytestisnegative • Neck • Nothyromegaly • Abdomen • Soft,non‐tender,non‐distended,noherniasor masses,normalbowelsounds • OfficePracticeCaseSimulation • Pelvic • Normalexternalgenitalia • Urethralmeatusappearsnormal • Vaginalmucosawithoutlesion,moderatebloodinvault • Cervixwithoutgrosslesions • Uterusnormalsize,shapeandcontour,nomasses • Noadnexalmassesortenderness WhatisyourDifferentialDiagnosis?

  10. 4/18/2018 WhatisyourDifferentialDiagnosis? AbnormalUterineBleeding(AUB)Heavymenstrualbleeding(AUB/HMB)Intermenstrualbleeding(AUB/IMB) *Alwaysr/opregnancy PALM:StructuralCausesPolyp(AUB‐P)Adenomyosis(AUB‐A)Leiomyoma(AUB‐L) Submucosalmyoma(AUB‐LSM)Othermyoma(AUB‐LO)Malignancy&hyperplasia(AUB‐M) COEIN:Non‐structuralCausesCoagulopathy(AUB‐C)Ovulatorydysfunction(AUB‐O)Endometrial(AUB‐E) Iatrogenic(AUB‐I) Notyetclassified(AUB‐N) Whatadditionalwork‐updoyouwant? • Whatadditionalwork‐updoyouwant? • TSH • CBC • Pelvicultrasound • Youscheduleafollowupappointmenttodiscussallresultsandfurthermanagementin2weeks

  11. 4/18/2018 • Follow‐upVisit • Yourpatientreportsthatherbleedingfinallystoppedabout5daysago.Shehasnonewcomplaints. • Labs • TSH:3.5mIU/ml(normal:0.4‐5mIU/ml) • Hemoglobin:10g/dL • Endometrialbiopsy:benignsecretoryendometrium • Pap:ASCUS,HPVneg • Gonorrhea:negChlamydia:neg Ultrasound Theuterusisantevertedandmeasures8x6x5cm.Theendometrialstripemeasures8mm.Theovariesappearnormal. • Management • Giventheevaluationresults,whatmanagementoptionswouldyoudiscusswiththispatientwhohasAUBandalsodesirescontraception?

  12. 4/18/2018 • Management • MirenaIUD • CombinationOCP • Oralprogesterone(continuousvscyclic) • DMPA • BTLandendometrialablation • Communication/Relationship Development • Introduceyourself • Sitdown • Makeeyecontact • Allowthepatienttotalk • Summarizewhatyouarehearingfromthem • Summarizeyourplan • Askthemiftheyunderstandthemanagementcareplan • ReviewofContraception • MechanismofAction • Progestin • NegativefeedbackonLH • Increasecervicalmucus • Preventscapacitationofsperm • Estrogen • SuppressesreleaseofFSH • Acceleratesovumtransport

  13. 4/18/2018 • ReviewofContraception • Reviewasagroupthebenefits,disadvantagesandcontraindicationsforeachofthefollowing: • CombinationOCP • ProgesteroneonlyOCP • Ortho‐Evrapatch • Nuvaring • DMPA • Nexplanon • Mirena/SkylaIUD • ParagardIUD • OfficePracticeCaseSimulation • YourpatientelectsforaMirenaIUD: • Discusshowyouwouldconsentyourpatientfor thisprocedure • ReviewofInformedConsent • Elementsofinformedconsent • Thenatureofthedecision/procedure • Reasonablealternativestotheproposedintervention • Therelevantrisks,benefits,anduncertaintiesrelatedtoeachalternative • Assessmentofpatientunderstanding • Theacceptanceoftheinterventionbythepatient • Reasonablepatientstandard • Whatwouldtheaveragepatientneedtoknowinordertobeaninformedparticipantinthedecision?

  14. 4/18/2018 • OfficePracticeCaseSimulation • Yourfacultyfacilitatorwillreviewkeypoint andPearlsrelatedtoMirenaIUDinsertion • PerformIUDinsertionsimulation • Self‐DirectedLearning • CriticalAppraisalofLiterature • Asagoodresident,youliketoreadeachnightaboutsomethingyousawthatday.YouarewonderingifaMirenaIUDisreallythateffectiveatcontrollingAUB. • CriticalAppraisaloftheLiterature • Reporting • Purposeandhypothesisclearlystated? • Isthestudyrelevant? • Studydesign • Prospectivevs.retrospective? • Randomized? • Appropriatecontrols? • Reproducible? • Applicabletoyourpatientpopulation?

  15. 4/18/2018 • CriticalAppraisaloftheLiterature • Executionofstudy • Adequatesamplesize? • Confoundingvariables? • Attritionrate/appropriatef/utime? • Appropriatestatistics? • Assessmentofconclusion • Dofindingssupportconclusions? • Clinicalvs.statisticalsignificance? • Application • Isthishelpfultoyourpractice? • Ideasforfutureresearch? Thankyouforyourparticipation! Pleaseremembertofilloutyour post‐courseevaluationpriortoleaving.

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