ASSOCIATION OF PROFESSORS OF GYNECOLOGY AND OBSTETRICS

Obtain a medical history in a pregnant woman with abdominal pain

Learner Task: Obtain a medical history in a pregnant woman with abdominal pain.
 
Educator Script: Provide the following pertinent patient history of a pregnant woman with abdominal pain as asked by the learner:

• HPI:  Gravida 2, Para 1, 38 weeks plus 3 days by LMP and US dating. Patient is in town for her sister’s wedding and noticed leakage of clear fluid 4 hours ago. Patient complains of non-radiating lower abdominal pain that began 2 hours ago. Pain is intermittent, every 4-5 minutes, each episode lasting for 30 seconds. Nothing makes the pain better or worse. +FM, No VB. Denies nausea, vomiting, pain/burning on urination. Patient is a non-smoker, denies hx of drug abuse or trauma.
• PMH:  None
• PSH:  None
• Meds: Prenatal Vitamins
• Allergies: Penicillin>anaphylaxis
• P Ob Hx: NSVD-female infant weighing 6 pounds, 12 oz. She was in labor for 36 hours and pushed for 3 hours. Baby spent one week in NICU for GBS infection.
• Prenatal Labs: O+, antibody negative, RPR-NR, Rubella Immune, Hep B Surface antigen negative, HIV negative, GC negative, Hemoglobin electrophoresis AA, CF screen negative, Pap test negative for malignancy, 50 gm Oral Glucose Challenge Test 115, GBS+.
• First and second trimester ultrasound: Unremarkable, c/w LMP.
• P Gyn Hx: Menarche at age 13, menstrual cycles q28-30 days lasting 4-6 days, denies dysmenorrhea or dyspareunia, coitarche at age 17, 5 lifetime male partners, denies history of sexually transmitted infections or abnormal Pap test.

Educator Checklist: HPI
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.
 

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.