This rotation showed me that OBGYN is more multifaceted of a specialty than I had thought it to be. The variety in caseload and settings exceeded my expectations. Spending two weeks in the outpatient clinic, I saw a variety of health maintenance visits and acute complaints from both pregnant and non-pregnant patients. During my two weeks on the labor and delivery floor, I triaged patients, helped with vaginal deliveries, and got OR experience assisting in cesarean sections and sterilization procedures. During my gynecology week, I saw many post-partum patients and ED consults, and again got to participate in the OR. I was not expecting so many different opportunities! This rotation also facilitated my understanding of the OB/GYN healthcare team. I now know the difference between midwives and OB/GYN NPs, which I did not previously. I worked closely with the labor and delivery nurses and now understand the role to be more specialized than I had previously thought. I also have a better understanding of the roles of the OB-GYN PA and the OB-GYN doctor, and how their roles fit into the careteam on a larger scale. I think much about this rotation surprised me, and I enjoyed it very much!
Site Visit Summary
My site visit with Professor Melendez was the first Site Visit that I’ve completed as an individual rather than in a group. This brought a new dynamic with new benefits and challenges that I enjoyed adapting to. Particularly, I appreciated getting to participate in a dialogue where I had to explain my clinical decision-making. I think the individual attention allowed for more specific guiding questions to be asked to me, and I found that to be very valuable. Specifically, during my first site evaluation, we had an interesting discourse requiring when a vaginitis panel would or would not be appropriate to perform. Patients often endorse having vaginal discharge, but that oftentimes may be a non-pathological physiologic change. Still, it would be in best practice to perform a vaginitis panel whenever discharge is reported and documented in the HPI. Discussing thorough documentation and treatment plans is a very important part of my clinical education, so this was very valuable!
R3 Typhon Log
R3 Journal Article
Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review
Rahman M, King C, Saikaly R, et al. Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review. Cureus. 2024;16(3):e55785. Published 2024 Mar 8. doi:10.7759/cureus.55785
Pain control and anxiety management during intrauterine device (IUD) insertion should be a highly prioritized aspect standard of care during the procedural treatment plan. In fact, pain perceived by females during intrauterine device insertion often limits the use of this effective contraceptive method. However, there is said to be a gap in the literature regarding official procedures for pain management during IUD implantation. This recently published systematic review sought to analyze pain control options during IUD insertion. Regarding pharmacological methods, local agents were significantly more effective in controlling pain than systemic agents including intramuscular naproxen, diclofenac, ketorolac, and prophylactic oral ibuprofen, none of which produced effective pain relief. This suggests that it is important to have a drug act directly in the vagina and on the cervix to manage pain during IUD insertion. Specifically, lidocaine administration via paracervical block appears to be most effective option and should be utilized more frequently by clinicians performing IUD insertion procedures.
R3 H+P
History
Identifying Data:
ID: 30yof
Address: Brooklyn, NY
Date & Time of Encounter: 3/19/24, 9:10am
Location: Woodhull OB/GYN Clinic
Source of Information: Self
Source of Referral: PCP
Chief Complaint: “I haven’t had a pap smear in many years”
History of Present Illness:
30YOF G3P3003 presents to establish gynecological care, with referral from PCP. Pt estimates she has not received health maintenance gyn care for about 8 years, which is when she estimates her last Pap smear was. Denies h/o abnormal pap results. States she is currently sexually active with only her husband. They do not use any contraception, which Pt declines interest in using. Reports LMP 3/5/24. Pt had HIV and HepB screens at Woodhull earlier this year. Results show HepB non-immune status, and Pt would like to begin vaccine series today. Denies h/o STDs, agrees to GC/CT and syphilis testing in-office today. Pt reports mild vaginal pruritus and increased discharge beginning about 4 days ago, notes that she is in the middle of her menstrual cycle so she believes symptoms may be 2/2 ovulation. Denies foul odor, colored or thick discharge, vaginal lesions, or pelvic pain. Pt notes her maternal grandmother died from “vaginal cancer,” denies family h/o other cancers, including breast.
Past Medical History:
Present chronic illnesses – Denies
Past medical illnesses – Denies
Childhood illnesses – Denies
Immunizations – Pt is not vaccinated against HepB, agrees to begin vaccine series today. Vaccines are otherwise up to date, including annual COVID-19 and annual influenza vaccines.
Screening tests and results – Last PAP smear ~2018, reports normal results. Pt has never undergone mammography or colonoscopy.
Obstetric History: G3P3003, 2xNSVD and 1xCS. LMP: 03/05/2024.
Past Surgical History:
Cesarean Section – age 28, Woodhull Hospital, Brooklyn, NY. No complications.
Denies past injuries or transfusions.
Medications:
Denies use of medications.
Vitamins and Supplement – Daily Women’s Multivitamin, unknown content, unknown dosage, once a day, last dose yesterday AM.
Allergies:
NKDA
Denies environmental or food allergies.
Family History:
Maternal grandmother – Deceased at 74 from “vaginal cancer”
Mother – 59, alive and well
Sister – 25, alive and well
Son – 7, alive and well
Daughter – 4, alive and well
Daughter – 2, alive and well
Social History:
PT has been married to her husband for 8 years. They live together with their three children.
She works part-time at a grocery store.
She denies drinking any alcohol, smoking cigarettes/cigars, or using illicit drugs.
She reports a mostly sedentary lifestyle, she is not active aside from walking to and from local locations.
She is currently sexually active with only her husband. Denies history of sexually transmitted diseases. Will undergo STD testing during today’s visit.
Review of Systems:
General – Denies recent weight loss or gain, fever, or recent illness.
Skin – Reports mild vaginal pruritus. Denies vaginal skin changes/lesions.
Breast – Denies tenderness, nipple discharge, dermatological changes, or vascular changes.
Gastrointestinal system – Denies change in appetite, nausea, vomiting, diarrhea, abdominal pain, or blood in stool.
Genitourinary system – Denies urinary frequency or urgency, dysuria, or flank pain.
Menstrual/Obstetrical – G3P3003. LMP 3/5/24. Reports regular menstrual cycle. Reports last Gyn exam was ~8 years ago.
Psychiatric – Denies anxiety or depressed mood. Denies psychiatric history.
Physical
Vital Signs:
Wt: 256
Ht: 68
BMI: 38.9
Temp: 98F, oral
Pulse: 63 bpm, regular rate and rhythm
Resp: 22 rpm, unlabored
Sp02: 100% on room air
BP: 118/84, seated L arm
General:
Well-nourished and well-groomed Hispanic female that looks her stated age. Attentive and conversational.
Skin:
Warm & moist, good turgor. Nonicteric.
Lips:
Pink, moist, no cyanosis or lesions.
Lungs:
Respirations unlabored with no paradoxical respirations or use of accessory muscles noted. Chest expansion symmetrical.
Abdomen:
Abdomen flat and symmetric with well-healed midline transverse surgical scar on lower abdomen.
Pelvic/Bi-Manual:
Vulva grossly intact, no lesions noted. Vagina with normal physiologic discharge, no masses, no odors noted. Cervix without lesions, no CMT. Uterus palpable, non-tender, no gross asymmetry noted. Adnexa nontender, non-palpable.
Assessment
30YOF with a healthy GYN assessment. Pap + STD testing pending, and Pt to begin HepB vaccine series today.
Notable differentials:
- Pt reports increased vaginal pruritus and clear discharge this week. Gyn exam is normal. Some possible differentials include:
- Physiologic leukorrhea
- Pt is mid-cycle and likely ovulating. Pt reports some increased whitish/clear discharge with no odor, confirmed on gyn exam. This is consistent with physiologic discharge, which I am very confident is what this Pt is experiencing.
- Contact dermatitis
- The perineal area can be sensitive to new soaps, fabrics, or other products it contacts, especially because vaginal pH and flora is sensitive. Mild itching and even increased vaginal discharge might be an inflammatory reaction to an irritating contact. There was no skin irritation on exam and PT did not mention any new products, so this is less likely.
- Bacterial vaginosis
- BV can also present with copious whitish/clear discharge, but usually with an abnormal odor and a more substantial amount than the patient reports, so BV is low on my differential, but important to include.
- Physiologic leukorrhea
Problem List and Plan
- Encounter for Gynecological Health Maintenance
- Pap smear
- GC/CT testing
- Vaginitis Panel
- Syphilis testing
- RTC in 1 year for annual wellness exam
- HepB Non-Immune status
- Administer Vaccine #1 of Engerix-B/Recombivax HB vaccine series
- RTC 1 month for Vaccine #2
R2 Reflection
My long term care rotation at Gouverneur exceeded my expectations. Before the rotation, I didn’t have a great understanding of the daily operations of the clinical team in the long term setting. I was surprised to find the case variety that I saw and the clinical correlations that I made to be very educational and rewarding. As a result of this rotation, I feel much more comfortable detecting abnormal findings on physical exam and developing plans for large and complex problem lists. My preceptor allowed me a lot of independence to evaluate patients and develop plans on my own. She would then double check my findings and offer validation and/or constructive criticism of my plan. I initially found this to be challenging, but looking back now, I realize how important it was to my growth and confidence as a future PA.
R2 Case Log
R2 Site Visit Summary
My two site visits helped me to practice my ability to concisely present patients to clinicians who are otherwise unfamiliar with my patients’ cases, a skill that I know I will continue to develop and execute throughout the course of my career as a PA student and PA. I enjoyed getting to hear my classmates do the same, as listening to patient presentations and extracting the pertinent information is another skill that is of utmost importance. I appreciated how collaborative the dynamic of these site visits were, I engaged in many insightful and constructive conversations about assessments, differential diagnoses, and plans, which are areas where I specifically am looking to strengthen because sometimes I struggle to articulate my thought processes. I learn best when I am able to work with my peers instead of as an individual, so overall, I really enjoyed how my site evaluator facilitated our visits as they were particularly valuable learning experiences to me.
Journal Article
“Oral Simnotrelvir for Adult Patients with Mild-to-Moderate Covid-19“
Cao B, Wang Y, Lu H, et al. Oral Simnotrelvir for Adult Patients with Mild-to-Moderate Covid-19. N Engl J Med. 2024;390(3):230-241. doi:10.1056/NEJMoa2301425
Summary:
Nirmatrelvir-ritonavir, also known as Paxlovid, shows efficacy in reducing hospitalization and death from COVID-19 and is approved for such use in the United States. However, its numerous drug interactions pose challenges in certain patients, such as my geriatric patient recently diagnosed with COVID-19. This very recent double-blind, randomized, placebo-controlled trial sought to investigate the efficacy of Simnotrelvir-ritonavir, a protease inhibitor combination similar to Paxlovid with fewer drug interactions.
This study assigned patients who had mild-to-moderate COVID-19 with onset of symptoms within the past 3 days to receive 750 mg of simnotrelvir plus 100 mg of ritonavir or placebo twice daily for 5 days. The results indicate that a 5-day course of simnotrelvir-ritonavir led to a 1.5-day reduction in the time to symptom resolution, and none of the participants progressed to severe disease or died by day 29. This drug has received emergency approval in China and it will be interesting to see if it is approved in the U.S. given its apparent efficacy and preferred drug interaction profile.
SE 2.1 – H&P
Identifying Data:
C.W, 85YOF
Date & Time of Encounter: 2/9/2024 11:15
Chief Complaint: NA/Admission H+P
History of Present Illness:
85yof w/PMH of HTN, DM2 w/ neuropathy (a1c 7.7%), obesity, GERD, OA, CKD3, and asthma admitted to NYP on 2/5/24 after being found down >24hrs after unwitnessed mechanical fall at home. Pt reports she was ambulating home alone when she tripped over a pack of cans on her floor and was unable to get back up until her HHA found her the following day.
At NYP, PT found to have NSTEMI, dehydration w/ mild rhabdo, b/l LE edema, asymptomatic +UA. No acute traumatic injuries found. NSTEMI determined likely 2/2 demand, although TTE (+) for hyperdynamic LV, no intraventricular thrombus, and segmental WMA consistent with CAD. Lactate cleared and CK downtrended over hospital course. Edema improved. PT refused treatment for asx UTI. Lantus decreased from 15u to 8u, aspirin initiated.
Today, PT seen and evaluated at bedside, A&Ox4, no signs of acute distress. States she is tired, but is feeling well otherwise. Reports worsening BLE pain 2/2 diabetic neuropathy, worse with palpation, R>L. Denies pain elsewhere. She has been ambulation with a walker and 1-assist, she is continent of stool but notes increasing urinary incontinence over the last year with increasing urinary frequency and urgency. Denies dysuria, flank pain, fever. Denies constipation. Says her appetite is less than prior to hospitalization, but that she believes she is still eating and hydrating adequately. Pt noted SpO2 92% on RA, denies h/o supplemental O2, denies palpitations, SOB, difficulty breathing, CP.
History:
Present chronic illnesses –
- HTN
- DM2 w/ neuropathy
- Obesity
- GERD
- OA
- CKD
- Asthma
Past medical illnesses – Depression in the 1960s, since resolved
Childhood illnesses – Denies
Immunizations – Up to date, including COVID-19 and influenza vaccines this year
Screening tests and results – Unknown
Past Surgical History:
- Hysterectomy
- Cataract Surgery w/ artificial lens
Medications:
- metFORMIN HCl ER 500 MG, 1 tablet two times a day
- Irbesartan Tablet 150 MG, 1 tablet one time a day
- Aspirin Oral Tablet Chewable 81 MG, 1 tablet one time a day
- Glimepiride Oral Tablet 1 MZG, 0.5 tablet one time a day
- Famotidine Tablet 20 MG, 1 tablet two times a day
- Chlorthalidone Tablet 25 MG, 1 tablet one time a day
- Simvastatin Tablet 20 MG, 1 tablet at bedtime
- SitaGLIPtin Phosphate Tablet 100 MG, 1 tablet one time a day
- Latanoprost Solution 0.005 %, 1 drop in both eyes at bedtime
- Carvedilol Tablet 12.5 MG, 1 tablet two times a day
- Nystatin Powder 100000 UNIT/GM, topically two times a day
- Brimonidine Tartrate Solution 0.15 %, 1 drop in both eyes three times a day
- Basaglar KwikPen Solution Pen-injector 100 UNIT/ML, 8 unit subcutaneously at bedtime
- Acetaminophen Tablet 325 MG, 2 tablet every 8 hours as needed
Vitamins and Supplement: Denies
Allergies:
NKDA, denies food and environmental allergies.
Family History:
Grandparents, deceased at unknown ages from unknown causes
Mother, deceased at 81, DMT2
Father, deceased at 69, DMT2, HTN, AMI
Son, deceased at 54 from traumatic injury
She has two daughters, 61 and 64, alive and well
Social History
C.W. is widowed and lives alone in a studio in Manhattan.
She receives assistance from an HHA 5 days a week, 4 hours a day.
HHA completes all IADLs with the exception of finances.
Pt reports she is primarily independent in all ADLs, however, toileting, bathing, and putting on socks/shoes has become increasingly difficult over the last year.
She is a retired elementary school support staff member.
She denies alcohol intake.
She is a previous smoker, ~70 pack/years.
She has 2-3 cups of coffee daily.
She denies illicit drug use.
She denies recent travel.
She reports a diet sufficient in fruits and vegetables, says that majority of meals are home-cooked by HHA.
She reports a mostly sedentary lifestyle
She reports getting 7-8 hours of sleep each night. She notes quality has worsened since her hospitalization.
She is not sexually active.
Review of Systems:
General – Reports fatigue since hospitalization. Denies fever, weight loss, weight gain.
Skin, hair, nails – Reports dry skin on B/L LE painful to touch. Denies vascular changes, color changes, rashes, or skin lesions.
Head – Denies dizziness, syncope, or head trauma.
Eyes – Denies changes in vision, discharge, or erythema. Notes 20/20 vision after corrective cataract surgery.
Ears – Denies changes in hearing, pain, or discharge.
Nose/sinuses – Denies nasal congestion, sinus congestion or sinus tenderness.
Mouth/throat – Reports globus sensation after eating bacon that has since resolved. Denies sore throat or voice changes. Last dental exam 2021.
Neck – Denies swelling, tenderness, or stiffness.
Pulmonary system – Denies cough, wheezing, pleuritic pain, or dyspnea.
Cardiovascular system – Denies CP, palpitations, edema.
Gastrointestinal system – Reports she is eating less than usual since hospitalization. Denies abdominal pain, constipation, nausea, vomiting, diarrhea.
Genitourinary system – Reports urinary frequency and urgency with worsening incontinence over the past year. Denies dysuria or flank pain.
Nervous – Reports constant B/L LE neuropathy with worsening pain to touch. Denies ataxia, paresthesias, h/o CVA.
Musculoskeletal system – Reports generalized muscle weakness since hospitalization. Denies pain or abnormal range of motion.
Peripheral vascular system – Reports B/L LE edema that has improved since hospitalization. Denies varicose veins or cold extremities.
Hematological system – Denies easy bruising or bleeding, h/o blood transfusions, or h/o DVT/PE.
Endocrine system – Denies heat or cold intolerance, excessive sweating, or excessive thirst.
Psychiatric – Reports depression in the 1960s that has resolved since. Denies anxious or depressive mood.
Physical
Vital Signs:
Wt: 227.2
Ht: 65”
BMI: 37.8
Temp: 97.8, oral
Pulse: 72 bpm, regular rate and rhythm
Resp: 18 rpm, unlabored
Sp02: 92% on room air
BP: 120/74 Lying/L Arm
BGL: 236 mg/dL
General: Well-nourished, neatly groomed Black female, A&Ox4, that looks her stated age, engaging appropriately with conversation. Pt appears comfortable, lying semi-fowlers in bed without signs of acute distress.
Skin, Hair and Nails: Dry, cracking skin on B/L forelegs. Skin is otherwise warm & moist with good turgor. Nonicteric, no lesions noted. No visible tattoos or markings. Hair is average quantity and distribution. Nails without clubbing, no discolorations, capillary refill <2 seconds in upper extremities B/L.
Head: Normocephalic and atraumatic.
Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual fields full OU.
Ears: Symmetric and appropriate in size. No lesions, masses, or evidence of trauma on external ears. No discharge or foreign bodies in external auditory canals AU.
Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nares patent bilaterally.
Sinuses: Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth: Lips, oral mucosa, and palate pink, moist, no cyanosis or lesions. Good dentition with no obvious dental caries noted. Gingivae are pink and moist without hyperplasia or masses. Tongue is pink and moist without masses, lesions or deviation.
Oropharynx: Well hydrated, with no exudates, masses, erythema, or lesions. Tonsils are present with no erythema or exudates. Uvula midline, with no lesions.
Neck: Trachea midline. No masses, lesions, scars, or visible pulsations noted. No palpable cervical adenopathy. Thyroid non-tender, no thyromegaly, no palpable nodules noted.
Chest: Respirations unlabored with symmetrical chest wall expansion. Non-tender to palpation throughout.
Lungs: Mild crackles in lower lobes B/L, otherwise clear to auscultation without adventitious breath sounds.
Heart: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen: Abdomen non-distended, all four quadrants are nontender to palpation, no guarding or rebound noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
GU: Bladder is nondistended, no suprapubic tenderness.
Neurologic: Symmetric muscle bulk with good tone of upper and lower extremities. UE strength 4/5 B/L and LE strength 3/5 B/L. No atrophy, tics, tremors or fasciculations appreciated. Intact to light touch and sharp/dull sensation throughout. Patellar Reflex 2+ B/L. Gait unable to be observed at time of exam.
Extremities (Peripheral Vascular/MSK): Mild, non-pitting edema of B/L calves and ankles (lateral>medial). Calf tenderness to light palpation B/L that PT reports is consistent with h/o diabetic neuropathy. No additional soft tissue swelling, erythema, ecchymosis, atrophy, deformities, tenderness or crepitus noted B/L. Skin is normal in color and warm to touch upper and lower extremities B/L, pedal pulses 2+. No palpable cords, varicose veins, cyanosis, or clubbing appreciated on LE B/L.
Assessment:
85yof PMH of HTN, DM2 w/ neuropathy (a1c 7.7%), obesity, GERD, OA, CKD3, asthma, h/o cataracts w/ artificial lens b/l; hospitalized and treated after mechanical fall with associated NSTEMI, dehydration w/ mild rhabdo, b/l LE edema, asymptomatic +UA; deemed stable for hospital discharge and admission to SAR.
Plan:
Problem List:
- NSTEMI likely 2/2 CAD
- BLE edema
- HTN
- HLD
- stop chlorthalidone 25mg QD given kidney dysfunction
- continue with aspirin 81mg
- continue with irbesartan 150mg QD
- continue with carvedilol 12.5 BID
- continue with simvastatin 20mg QD
- monitor BLE edema
- continue with weekly weights x 4 weeks
- hx of rhabdomyolysis
- generalized muscle weakness
- continue with PT, OT, 1-assist with ADLs, careful OOB and ambulation with walker
- DM2 w/ neuropathy
- continue with metformin ER 500mg BID
- continue with basaglar 8u HS
- continue with sitagliptin 100 QD
- continue with glimepiride .5mg QD
- GERD
- continue with famotidine 20mg BID
- OA
- continue with APAP 325mg q8prn
- h/o cataracts, artificial lens b/l
- continue with latanoprost 1 drop HS
- continue with brimonidine 1 drop TID
- ophtho f/u prn
- CKD3
- avoid nephrotoxic agents
- monitor renal fxn
