Certifying Exam Cases

At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician.

We aim to teach the presentation and management of cardiovascular emergencies through the creation of a flipped classroom design. This unique, innovative curriculum utilizes resources chosen by education faculty and resident learners, study questions, real-life experiences, and small group discussions in place of traditional lectures. In doing so, a goal of the curriculum is to encourage self-directed learning, improve understanding and knowledge retention, and improve the educational experience of our residents.

By the end of this oral boards case, the learner will be able to: 1. List the potential causes of vaginal bleeding in pregnancy after 20 weeks including placental abruption, placenta previa and vasa previa. 2. Describe the bedside stabilization and evaluation in a pregnant patient with vaginal bleeding after 20 weeks. a) Stabilize the mother (patient) including placing two large bore intravenous (IV) lines, administer an IV fluid bolus, obtaining complete blood count (CBC), coagulation studies, and type & cross matching blood. b) Transvaginal ultrasound to determine the placental location. c) Sterile speculum examination. A digital or speculum pelvic examination should NOT be performed until a transvaginal ultrasound is performed to determine placental location. The resident should understand that performing a digital or speculum exam in a patient with placenta previa or vasa previa can cause or exacerbate hemorrhage. If these two conditions are not present on ultrasound, then a sterile speculum exam may be performed to further examine the bleeding. 3. Contrast the typical presentation of placenta previa with that of placental abruption. a) Placenta Previa usually causes painless vaginal bleeding. Part of the placenta is located near or over the internal cervical orifice. b) Placental Abruption usually causes painful vaginal bleeding. There is premature separation of the placenta from the uterine lining. 4) Describe the appropriate disposition of a patient with a pregnancy over 20 weeks with vaginal bleeding. After initial workup and stabilization these women are usually admitted for fetal monitoring, observation and consultation by the obstetrician (OB/gyn).