Rotation 6 OBGYN

OBGYN

H&P

C/C: “My vagina feels itchy” x 3 weeks

HPI: F.M. is a 58 y/o F G2P2002, 2 NSVD, LMP: 09/30/2012 c/o vaginal itch x 3 weeks. The pts states the pruritus started late August and has gradually increased over the past few weeks. It is constant and not alleviated or aggravated by anything. She is not sexually active and denies history of STIs. She reports that she has not changed any soaps, detergents, or recently used antibiotics. Pt denies vaginal odor, discharge, pain, dysuria, vaginal bleeding, fever, chills, chest pain, SOB.

ROS:

Gen – Denies fever, chills, night sweats, and weight change

Pulm – Denies SOB, cough

CV – Denies chest pains, palpitations,

OB: G2P2002, 2NSVD

Gynecological: Admits to menopause at 50 y.o. vaginal dryness and pruritis. Denies vaginal bleeding, vaginal discharge, pelvic pain, rectal bleeding, dysuria, hesitancy, urgency, incontinence, abnormal, breast mass, breast discharge. Admits to self-breast exams. Last mammogram 11/22/2019- normal, pap smear 8/15/2018- normal, no hx of abnormal pap smears. Denies h/o STIs or PID, Denies h/o fibroids or ovarian cysts.

PMHx:

Current medical conditions – COPD, diverticulosis, hypothyroidism, GERD.

Past Medical Conditions – Denies past medical history

PSHx – Denies

Current medications –Levothyroxine 88 PO mcg qd for hypothyroidism.

Pantoprazole 40mg PO qd x 4-8 weeks for erosive esophagitis

Allergies – NKDA, denies environmental and food allergies

Family hx – Denies history of breast, ovarian and endometrial ca

Social hx – Former smoker. Denies alcohol/illicit drug use. Single and denies being sexually active

DDx: 

  1. Estrogen Deficiency
  2. Vulvar lichen sclerosus
  3. Lichen planus
  4. Vulvar cancer

VS: T 98.6F, HR 88 bpm, BP 124/64 Rt arm sitting, RR 18, SpO2 100%, BMI 16

PE:

Gen – Alert & oriented. No acute distress.

Abd –Soft, non-tender, non-distended

GU – No rashes, warts, no Bartholin gland edema, dry vaginal mucosa with atrophy, no discharge, Vulva patches of depigmentation and white papules on labia minora. Cervical os observed without discharge. Loss of folds between labia minora and majora making them almost indistinguishable.

Labs/Procedures:

No labs/Procedures.

Refined DDx:

  1. Vulvar lichen sclerosus
  2. Estrogen Deficiency
  3. Vulvar cancer

Assessment: 58 y/o F w/ h/o COPD, diverticulosis, hypothyroidism, GERD, G2P2002 LMP: 10/31/2012 c/o vaginal itch x 3 weeks. Presentation is most consistent with vulvar lichen sclerosus.

 Plan:

  1. Vulvar lichen sclerosus
    1. Clobetasol 0.05% cream 1 application 2 times a day for 3 weeks and then taper to 2 times per week on week 4, apply a thin layer on the external labia
    2. Explanation of dermatological changes that have occurred on the vulva.
    3. F/u in 1 month
  2. Pap due 8/2021. Informed the patient that her next Pap will be her last one.

Typhon:

OBGYN Typhon

Article Summary:

I chose this article because it was related to my patient’s diagnosis. The disease described in this article is something that is not covered in the PA rotation and is not seen very often. This article gives a complete overview of vulvar Lichen Sclerosus, which is a chronic inflammatory dermatosis with ivory-white plaques that affect the vulva and anus. The article describes the first documented case and provides the theorized etiologies of the disease. In addition, it describes vulvar lichen sclerosus clinical features, differential diagnosis, and treatment. The treatment options range from hormonal therapy, topical steroids and even the use of phototherapy.

Journal Article

Site evaluation

The site evaluations I had for OBGYN were quite informative. The evaluator made sure that I focused on a good history especially the GYN history. This was evident by the fact that he made me focus on even the elderly patients and the importance of asking early menarche and the use of OCPs in the past. These two points are important in assessing a patient with GYN complaints. He also made sure that I knew my 5 drug cards and provided that I am able to implement them into specific patients.

Rotation Summary:

OBGYN rotation was a great experience. I was able to perform procedures and provide healthcare to both pregnant and postpartum patients with multiple chances of care. The patient population was underserved and that led to a much more hands on experience. The week within labor and delivery was extremely busy and it was somewhat difficult to manage all the laboring mothers. The professional diversity was a huge help while working at Woodhull. I spent a couple of days working with the Midwifes and they provided some great training on how to properly care for the mother delivering the baby. The Midwifes worked almost completely autonomously and were able to provide postpartum care immediately after delivery. The GYN-call rotation was very interesting because it provided a view of the patient hour to days after vaginal or c-section delivery. I was able to see several different medical conditions that I would not have been able to observe if working in a private practice setting. On occasion the women in clinic would not feel comfortable having a male student in the room while performing an examination. This was something that I had to get over because providing a comfortable environment is of the utmost importance when it comes to patient care. Without hesitation I would excuse myself and allow the practitioner to complete the exam. Oftentimes I would read the medical progress notes or H&P to get a better idea of what the findings were on the physical exam. Overall, I found this rotation to be rewarding and extremely helpful in preparing me as a physician assistant.
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