RT 1 – OB/GYN

History and Physical Write-Up

RT 1 – Site visit 2 H&P

Journal Article

Sepsis In Pregnancy – Journal Article 

This is an article about recognizing sepsis in the pregnant population. This was in fact relevant to the case that I presented to my preceptor which involved a younger pregnant patient who was experiencing a fever. The initial work up was giving us no direction as to what was causing the fever and deemed it a fever of unknown origin. The journal article introduces the topic of sepsis and how it is the 4th leading cause of maternal death and despite continuous updated sepsis guidelines, the mortality in pregnant patients continued to rise. The issue here is that pregnant patients have unique physiologic changes that occur during pregnancy that make it quite difficult to identify signs/symptoms of sepsis! An increased heart rate and cardiac output make mask baseline signs of sepsis. A decrease in vaginal pH increases the risk of chorioamnionitis. The dilation of the ureters poses are greater risk of pyelonephritis in these patients. These are just a few of the physiological impacts while there are many more. The article continued to discuss different disease states individually on a more in depth level regarding resuscitation and recognition of sepsis.The main takeaway here is that pregnant patients have anatomic and physiologic changes that can pose challenges for clinicians in recognizing and managing sepsis. Another key piece of information to note is that pregnant women are excluded from randomized controlled trials regarding sepsis guidelines. So further research needs to be conducted to help recognize and treat this disease even though it may be extremely difficult to find patients who are willing to participate in these types of trials.

Site Evaluation: My Summary

During my site visit I presented a case about a 21 year old pregnant patient at 23 weeks 0 day gestation with a chief complaint of fever. Patient was sent to the Labor and Delivery triage to be assessed as to whether she should be admitted to the hospital. The patient presented with a low grade fever of 100.3F and complained of sore throat and cough. After thorough history taking and labs returned, there was no obvious reason for why the patient had any of these symptoms and she was deemed of having a fever with unknown origin. It was interesting trying to work up a suspected septic patient and especially one that was pregnant. Her vitals demonstrated fever and tachycardia while fetal heart rate monitoring displayed fetal tachycardia in the 180s which was quite concerning. After administration of Tylenol and 2 L of fluid, her heart rate and fever came down but the baby’s baseline was still elevated to the 180s. For this she was admitted. The patient was soon admitted for this to definitively rule out sepsis.

I think I did a pretty good job presenting the case to my preceptor. I believe he understood the whole picture about what was going on with my patient.  I made sure to include the most appropriate information to present. I was told many times before that I tend to include information that necessarily does not relate or in fact help in any way in determining a plan for the patient. More is not always better. Even though I do believe I have improved in presenting patients, I know that I am far from where I want to be. I sometimes do not have my thoughts clear and concise and the best way to improve this is to take my time a little more and just simple repetition. Do as many as I can while taking and incorporating as much criticism as I can. Different rotations will require different ways of presenting and that was made very clear on the first day of OBGYN. The site evaluations were quite helpful.

Typhon Postings

RT 1 – OBGYN Typhon Postings

Self-Reflection 

Overall, I had a good experience with this rotation. Going into OBGYN, I did hear it was kind of tough and that kind of got me very nervous, because it being my first rotation I did not know what to expect. Professor Melendez really made us feel comfortable and told us to not be afraid to make mistakes and ask questions because that is how we learn as students. I learned a lot from doing routine pap smears and GYN exams, to assisting in C-sections, methods on inducing patients into labor and even how to suture.  I will list some questions below so that you can gauge my clinical experience in the OBGYN rotation.

Exposure to new techniques or treatment strategies – how did that go?

I must say, practicing pelvic exams on dummies in physical diagnosis lab is nothing like the real world. The PA and attendings make the speculum exam very easy and they almost instantly are able to find the patient’s cervix and perform the pap smear and C/G swab. Frustration sometimes took over my head as I was comparing my time in performing a speculum exam compared to the PA and attendings. Just needed to take a breather and not think to much and realize that some patients it is just harder to perform a pap smear in general and it not my technique necessarily. I had some trouble in the beginning but then was able to learn to quickly do it as I was able to perform a plethora of exams/swabs/smears during my two-week period in the Women’s Health Clinic.

I also was also given the chance to assist in 2 cesarean sections which was eye opening. Everyone in the OR moves very quickly. I got to say that the fallopian tubes, fimbrae, etc are scaled so much more differently in real life compared to pictures that I did not even know what I was looking at when I first visualized them. Towards the end of the C-section, I was given the opportunity to perform a running subcuticular stitch to close the skin. I was proud of myself for doing it because that was one stitch that  Prof. Lopez mentioned that was the “bread and butter” that needed to be mastered even though we were not specifically tested on it during clinical skills lab.

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

Working in the Women’s Health Clinic was eye opening I must say. Clinicians, for the most part, deal with patients that would listen and abide by their instructions or recommendations. At times, patients wont take into consideration what you are saying even though you have a medical background and are well educated in the manner at hand. Many instances I found myself dealing with patients who claim that nobody knows their body more than themselves and I applaud the PA whom I worked with often, Ms. Hammer, on her being able to respectively explain how something being different than usual can still be considered “normal” and nothing to worry about. Witnessing Ms. Hammer deal with those patients in front of me gave me an insight of how you are to act when patients begin to question what you are saying and not acknowledging what it is you have to say.

What is one thing you would want your preceptor or other colleagues to notice about your work in this rotation?

I want others to realize that I am not just there to be there. I am here to learn through real world experience and take any criticism that comes my way because that is how I know I will only continue to advance as a future clinician. I have a good attitude and I am not afraid to ask questions or say when I do not know things. I also want them to know that I pick things up quickly and really take the patient into consideration whether I am completely hands on or even just simply observing from the side.

What did you learn about yourself during this 5-week rotation?

I learned that I am smarter than I think I am. I just got to believe in myself more. I just get hesitant and do not want to mess up but that is how you learn and once you mess up one time, you will never forget it after that. I also learned that I need to manage my time a little better. Rotation schedules can be very tiring and if you do not manage your time properly you can fall behind on assignments and study time. I also learned that I need to just go with the flow more and not get irritated if something does not go your way the first time. I can be a perfectionist at times which can cloud my thinking sometimes. The OBGYN staff at Woodhull were very welcoming and friendly. When going into a new unit I can be nervous and shy at times  and they made it clear that you cannot be shy and you must introduce yourself to literally everyone you meet even if you do not know them. So, I actually now feel much more confident with approaching individuals, patients and initiating conversations which will certainly help me for the upcoming rotations.

I am going into my ER rotation at Staten Island University Hospital now and I will make sure to take advantage of every situation that I can. So far, the ER is an area I am really considering, and I cannot let this chance go to waste to learn as much as I can. Being that it will be my 2nd rotation, I will not feel as nervous because I kind of know what is to be expected of me and what it is that I expect of myself!