October 25-28, 2004 GU I / GYN I
GOALS AND INSTRUCTIONAL OBJECTIVES GOALS: By the end of the week, the first quarter student will have an in-depth understanding of the diagnoses listed under Primary Diagnoses and Secondary Common Diagnoses. The first quarter student will accurately perform an appropriate history and physical exam on a patient or patient model presenting with one of the genitourinary or gynecological diagnoses listed under Primary Diagnoses, Secondary Diagnoses, and Tertiary Diagnoses when seen at the student’s clinical site or during a practicum exam. OBJECTIVES: The first quarter student will complete the following: !
Accurately explain the epidemiology of primary and secondary common diagnoses.
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Name the (S) chief or common presenting complaint and relevant descriptors of the primary, secondary common and uncommon and tertiary diagnoses.
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Accurately distinguish between (O) Objective negative and positive findings while performing a routine or specialty physical exam technique when evaluating for, or in the presence of, the conditions listed for each primary, secondary common and uncommon, and tertiary diagnosis.
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The first quarter student will accurately perform a focused exam on a patient or patient model presenting with a risk for HIV, but is currently HIV negative .
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The first quarter student will describe or demonstrate the appropriate technique used to elicit CVA tenderness, supra-pubic tenderness, and prostatic tenderness and explain the potential clinical significance of a positive finding.
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Formulate a (A) Diagnosis and list relevant differential diagnoses from information gathered through history taking, physical exam, and diagnostic test results provided via case studies or reports or collected in the clinical setting.
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Identifies risks associated with specific missed diagnosis
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Identifies on written exam or in case presentation of a patient model or clinic patient, a
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(P) Plan outlining the appropriate medication, non-medicinal treatment, patient education and follow-up evaluation for primary and secondary common diagnoses.
(D) = definition only Musculoskeletal: ANATOMY AND PHYSIOLOGY The first quarter student will recognize and explain the anatomy, physiology, and common pathophysiology in sufficient depth for clinical application related to the following genitourinary and gynecological components. To meet this objective the student will utilize textbooks, models, electronic, computer or web-based programs, radiographic resources, and lectures according to the standards identified in the Primary Care Associate Program required texts (see booklist in Student Manual).
GU Kidney ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Nephron Tubule Glomerulus Renal pelvis Renal artery Costovertebral angle Bladder and related structures Bladder Bladder sphincter Ureter Urethra Urethral meatus (male and female structures) Male GU structures Penis Foreskin Scrotum Epididymis Testes Spermatic cord Prostate Seminal vesicles Physiology of micturition
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GYN Breast ! Glandular tissue ! Excretory ducts ! Lactiferous sinus ! Areolar glands (Montgomery's glands) ! Nipple ! Areola ! Suspensory ligament ! Pectoralis muscles ! Lymphatic system ! Extra numerary nipples External genitalia ! Pubic hair ! Mons pubis ! Labia majora ! Labia minora ! Clitoris ! Urethral meatus ! Introitus ! Bartholin's glands ! Skene's glands ! Hymen ! Vestibule ! Perineum ! Anus Internal genitalia ! Vagina ! Cervix ! Cervical squamocolumnar junction ! Nabothian cyst ! Internal and external cervical os ! Endocervical canal ! Uterus ! Endometrium ! Myometrium ! Fallopian tubes ! Ovaries ! Posterior cul-de-sac ! Fornix ! Rectovaginal septum G /IO -G U I /G Y N I (rev 8/04 rw)
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Uterosacral ligaments Broad ligament Round ligaments Peritoneum
Hormonal interactions and their expressions during the following. ! Puberty ! Menstrual cycle ! Pregnancy ! Lactation ! Menopause Hormonal mechanisms of the following. ! Menstrual bleeding (menorrhea) ! Amenorrhea ! Withdrawal bleeding ! Dysfunctional bleeding ! Menorrhagia ! Hypomenorrhea ! Metrorrhagia ! Polymenorrhea ! Menometrorrhagia ! Oligomenorrhea ! Post coital bleeding ! Galactorrhea
DISEASE Primary Diagnoses: The first quarter student will state the basic pathophysiology, etiological agents, and/or risk factors, preventive measures, signs and symptoms, differential diagnoses, investigative measures, management and patient education for the following diagnoses:
GU !
Benign Conditions • Benign prostatic hypertrophy (BPH) • Varicocele • Erectile dysfunction
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Infectious / Inflammatory Conditions • Anogenital warts • Genital herpes • Prostatitis < Acute < Chronic • Urethritis < Gonorrhea < Chlamydia • Urinary tract infection < Uncomplicated cystitis
GYN !
Vulvovaginitis • Trichomonas • Candidiasis • Bacterial Vaginosis • Contact dermatitis
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Contraception • Hormonal contraception < OC’s < Injectable < Patch < Vaginal ring < Implants • Barrier methods • IUD • Fertility awareness • Emergency contraception (morning-after pill)
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Sexually transmitted infections (STI) • Viral < Condylomata Acuminata < Herpes simplex < HIV < Human papilloma virus (HPV) • Bacterial < Gonorrhea < Chlamydia • Spirochetal disease < Syphilis
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PMS (Premenstrual Syndrome) • Dysmenorrhea
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Uterus • Dysfunctional uterine bleeding
Secondary Diagnoses (Common): The first quarter student will state the basic pathophysiology, etiological agents, and/or risk factors, preventive measures, signs and symptoms, differential diagnoses, investigative measures, general principles of management and patient education for the following diagnoses. Physician consultation is expected.
GU !
Benign Conditions • Hydrocele • Urethral and meatal stricture • Nephrolithiasis / urolithiasis (D)
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Infectious / Inflammatory Conditions • Pyelonephritis • Recurrent UTIs (reinfection or relapse) • Epididymitis • Syphilis • Balanitis
GYN !
Structural Abnormalities • Cystocele (D) • Rectocele (D) • Prolapse (D)
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Vulvar Abnormalities • Bartholin's gland cyst and abscess (D) • Gartner's duct cyst (D)
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Cervical Abnormalities • Cervical polyp • Cervicitis • Atypia, dysplasia of cervix (including carcinoma in situ)
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Uterus • Endometritis • Leiomyoma (uterine fibroids) • Endometriosis / adenomyosis
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Adnexa/Ovary • Ovarian cyst, functional • Ovarian cyst, non-functional (including teratoma) • Salpingitis (D) • Polycystic ovarian disease (PCOD)
Secondary Diagnoses (Uncommon): The first quarter student will state the basic pathophysiology, signs and symptoms of the following diseases.
GU !
Benign Conditions • Cryptorchidism • Phimosis / paraphimosis • Epispadias
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Infectious / Inflammatory Conditions • Chancroid • Lymphogranuloma venereum Malformations • Hydronephrosis • Posterior urethral valves • Horseshoe kidney • Duplication of ureters
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Renal Diseases • Polycystic kidneys
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Neoplastic Diseases • Testicular cancer
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Prostatic cancer Wilm's tumor
GYN ! ! ! ! ! ! ! ! !
Syphilis Vulvar cancer (D) Cervical carcinoma Lichen sclerosus atrophicus (D) Lichen planus (D) Cytomegalovirus infections (CMV) Granuloma inguinale Lymphogranuloma venereum (LGV) Toxoplasmosis
Tertiary Problems: Problems Requiring Emergency Management or Hospitalization: The first quarter student will be able to recognize these disorders and initiate treatment. As well, they should be able to describe and identify the basic pathophysiology, risk factors, preventive measures, patient education and appropriate referral sources:
GU ! ! !
Urosepsis Acute urinary retention Testicular torsion
GYN ! ! !
Incomplete spontaneous abortion Tubo-ovarian abscess Pelvic inflammatory Disease • (See Sexually transmitted infections above)
CLINICAL PROBLEMS For each problem the first quarter student will be able to perform a focused history G /IO -G U I /G Y N I (rev 8/04 rw)
and physical, generate a differential diagnosis, and order appropriate diagnostic tests. They will be able to present the problem orally, do a write-up in SOAP format, and manage the diagnoses in Primary and Secondary Common Diagnoses.
GU ! ! ! ! ! ! ! ! !
Hematuria Dysuria / urgency / frequency Flank pain Proteinuria Pyuria Urethral discharge Testicular mass Testicular pain Undescended testicle
GYN ! ! ! ! ! ! ! ! !
Vaginal discharge/odor/itching/irritation Contraception request STI’s exposure Dyspareunia Amenorrhea Dysmenorrhea Pelvic Pain Spontaneous abortion = miscarriage Menopause / HRT
OBJECTIVE In addition to the basic exam of this system, the student will be able to perform the following physical exam maneuvers:
GU ! ! ! !
Prostatic massage Hernia examination Evaluation of foreskin • Retractibility in children, diabetic patient, and elderly Transillumination of scrotum
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GYN ! ! !
Cervical motion tenderness (Chandelier sign) Collection of vaginal smear Collection of vaginal-cervical PAP smear
Recognize the listed abnormalities: GU ! ! ! ! ! ! ! !
Phimosis Paraphimosis Epispadias Varicocele Hydrocele Scrotal mass Cryptorchidism Prostatic mass or enlargement
PLAN Evaluation studies: State the indications for the following tests. Explain the significance of a normal vs abnormal result in relation to the diagnoses listed under Primary, Secondary Common and Uncommon, and Tertiary Diagnoses, and describe the general cost effectiveness of the following tests: Lab ! !
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Urinalysis and urine cultures Cultures • Vaginal • Cervical • Lab tests < strep cultures < DNA’s < DFA – urine tests 3-glass urine Gram stain < urine < prostatic fluid Cytology of urine and prostatic fluid VDRL, and other serology for syphilis BUN
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Creatinine (D) PSA (prostate-specific antigen) Wet preps • normal saline • KOH • Cytology (PAP) specimens • Cervix • nipple discharge Fern Test
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Radiology-Nuclear Medicine • Pelvic / vaginal sonography • Flat plate of abdomen • IVP
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Other Studies • Colposcopy • Chorionic villa sampling • Biopsy (D) < renal < prostate < Ultrasound
Treatment: The first quarter student will identify the indications, contraindications, adverse effects and describe the general cost effectiveness of the following treatment approaches: !
Medication
GU •
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Antibiotics < sulfonamides < ampicillin < penicillin < nalidixic acid < nitrofurantoin < trimethoprim - sulfamethoxazole < aminoglycoside Analgesics < codeine, meperidine < Podophyllin (20% in tincture of benzoin) < Urinary analgesic Pyridium
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GYN • • • • •
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Contraceptive jells, creams, foams, films Tetracycline’s/Doxycycline Azithromycin (Zithromax) Phenazopyridine (Pyridium) Antifungals - topical/oral < Nystatin [Mycostatin], Miconazole [Monistat], < Clotrimazole [Gyne-Lotrimin], fluconazole < [Diflucan], Terconazole [Terazol]) Trichloracetic acid/Bichloracetic acid Metronidazole (Flagyl) - oral, topical, vaginal Oral contraceptives and Progesterones Podophyllin Ibuprofen (Motrin) Ferrous Sulfate Antivirals (Acyclovir/Famvir) Estrogen (oral, vaginal, topical) Progesterone
Interventions to be conversant about: (be able to explain to patient) ! Dilation & curettage (D & C) ! Cervical biopsy ! Cryosurgery / LEEP procedure ! Conization of Cervix ! Vacuum Aspiration ! Dilation & evacuation ! Colposcopy ! Culdocentesis Procedures ! pH tape test of vaginal discharge-bacterial vaginosis, yeast, or ! amniotic fluid presence ! Cervical culture techniques ! IUD insertion and removal ! Diaphragm fitting ! Cytology (PAP) specimen of breast or cervix ! Norplant / Depo-Provera ! Ability to properly perform 3-glass urine ! Proper techniques to obtain specimen for C & S or stains ! Bladder catheterization Surgical Interventions: Understand the meaning of the following procedures.
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Cystoscopy TURP- trans-urethral resection of the prostate Vasectomy
Patient EducationThe first quarter student will be able to identify and then explain to patients the following topics: GU ! ! ! !
Education regarding UTIs STI prevention Testicular self exam Vasectomy
GYN ! ! ! ! ! !
Teach breast self-exam Family planning and birth control D&C Menopause / self-image of women at different stages of life Pap test results, biopsy and cryosurgery Hormone replacement therapy
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October 25-28, 2004 GU I / GYN I
READING ASSIGNMENT BA 8th ed Tortora 10th ed Wasson 5th ed Hatcher 17th ed DeCherney 9th ed Tierney 2004 43rd ed BBZ 6th ed Burke Saunders 4th ed Current Emergency Pfenninger 2nd ed Mettler Fischbach
Review lab studies listed in IO’s not already discussed in previous readings for sufficient understanding of when and why perform the test and the significance of the results.
PHARMACOLOGY: note: Review UTI handout from Dan Furtado’s lecture. Pharmacotherapeutics for Advanced Practice
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