Site Evaluation Reflection:

For my OB/GYN rotation at QHC site evaluation with Professor Melendez, we were required to write 3 H&Ps and 10 drug cards. Our site evaluation was on zoom and it was one on one. I presented a comprehensive initial obstetric visit at the Women’s clinic. I chose this case because it taught me how to take a good OB history on a patient who recently became pregnant. The patient was G2P1 and she was about 11 weeks gestation. Me and the patient asked the patient questions about her first pregnancy abroad, known genetic abnormalities in the family, plans for delivery (vaginal or c-section) and plans for breastfeeding etc. I learned to ask about contraceptive use after delivery as well. I was able to learn how to calculate gestation age using crown rump length on her first sonogram. Then we ordered an extensive list of bloodwork; including genetic testing for any abnormalities, STDs testing, checking for titers and then prescribed prenatal vitamins. 

My second case was an ED GYN consult. The patient G2P1, about 10 weeks gestation presenting with vaginal bleeding and pelvic for 4 days. Pt was here two days ago in the ED and was told that the pregnancy might be nonviable due to no fetal heart on ultrasound. She was told to come back in 2 days so her beta HCG can be monitored and for a repeat ultrasound. On ultrasound we were unable to see a fetal heart and her beta HCG dropped. The provider confirmed a nonviable pregnancy. With this case I learned how to have a conversation regarding a sensitive topic with the patient and how to sympathize with them. The patient was given Methotrexate and given instructions to return if bleeding becomes too heavy. For this case I presented an article called, “Mifepristone and Misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomized, double-blind, placebo-controlled trial.” The study basically concluded that the combination treatment using mifepristone plus misoprostol resulted in an increased number of completed missed pregnancies within the first 7 days compared to misoprostol alone and less surgeries needed. 

My last case was about a G3P2 patient who presented to OB triage with painful urination and itching in her vagina. We first put the baby on the tocodynamometer and made sure that the baby was not in distress. Then we did a speculum exam and noticed a thick white discharge. Pt was diagnosed with vaginal candidiasis and prescribed Miconazole suppository. With this case, I learned to check both the mom and the baby when they come into triage, even if the concern is with the mom only. We always need to make sure there is no immediate concern with the baby.

We also went over my drug cards and Professor Melendez taught me more about side effects of certain drugs. He also told me alternative drugs we can prescribe for the same constitution and the doses for each drug. After presenting my case, one feedback I was given was to not get into the habit of saying “normal” for any pertinent PE finding. For example, for a vaginal exam on a new pregnant mother, we should say what is “normal” such as the cervix is closed and no bleeding. This is because not everyone knows what we mean by saying “normal exam.” Another feedback I received is about clarifying details in my HPI. My first patient told us that she delivered her first child at 10 months, which even though it was odd, I did not clarify with the patient if she meant 9 months. I wrote 10 months in my HPI which was incorrect. Going forward I will definitely clarify details of my HPI with the patient. I would also make sure to be more thorough with my physical exam presentation instead of just briefly mentioning it. Overall I learned a lot with Professor Melendez because he took his time with each student. Since it was one on one, he was able to ask me more questions and look at my HPIs more closely and give better focused feedback.