Obtain a medical history in a reproductive-aged woman
Learner Task: Take a pertinent history in a reproductive woman.
Educator Script: Provide the following pertinent patient history of a reproductive-aged woman with pelvic pain as asked by the learner.
- HPI: Gravida 0, LMP 6 weeks ago
- P GYN Hx: Menarche at 12 years old, menstrual cycles q28-30 days lasting 4 days, moderate dysmenorrhea, no dyspareunia, coitarche at 16 year old, 2 lifetime male partners, treated for chlamydia 1 year ago, using condoms inconsistently for contraception, has never had a Pap smear.
- PMH: None
- Meds: None
- Allergies: No drug allergies
- PSH: Tonsillectomy and adenoidectomy
- Social History: She is in her senior year of high school, makes A’s and B’s in school. She is heterosexual and has had a boyfriend for a little over a year, they use condoms some of the time. She is in the school band, smokes occasionally, has tried alcohol, and denies drugs.
- Review of systems: Complains of loss of appetite today, nausea x 2 weeks, denies the following: vomiting, constipation, increased urinary frequency, vaginal discharge or odor, personal history of bleeding disorders, breast discharge or tenderness, headaches, sob, dizziness, chest pain, and fever.
Educator Checklist: History Taking
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
|Included =1||Not Included =0|
|Student introduced her/himself appropriately (first name, last name, medical student)|
|Student addressed patient as per patient preference|
|Student clarified purpose of visit|
|Student washed hands correctly (before touching patient)|
|Obtains accurate gynecologic history and sexual history|
|Obtains accurate obstetrics history|
|Obtains accurate review of systems for chief complaint||
|Obtains accurate past medical history|
|Obtains accurate surgical history|
|Obtains accurate medication use, asks about over the counter and herbal supplements|
|Obtains accurate allergy history|
|Obtains accurate family history|
|Obtains accurate social history including smoking, alcohol use, drug use|