Obtain a medical history in a reproductive-aged woman
Learner Task: Take a complete history from the patient.
Educator Script: Provide the following patient history as asked by the learner:
- HPI: She reports three episodes of vulvovaginal itching, with thick white vaginal discharge. She denies any odor to the discharge. Episodes started about two weeks ago. She has tried over the counter products, which help but do not completely eliminate the symptoms. She is not currently sexually active.
- PMH: None
- PSH: None
- POB History: 2 NSVDs, both pregnancies complicated by diet controlled gestational diabetes.
- Allergies: None
- Medications: None
- SH: Non-smoker, divorced. Works in billing at the hospital.
- FH: diabetes, no malignancies
- P Ob Hx: Last Pap test three years ago, no abnormal Pap tests. No sexually transmitted infections. History of five lifetime sexual partners, and has been sexually active with men.
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.
|Included =1||Not Included =0|
|Appearance of discharge|
|Frequency of episodes|
|Duration of symptoms|
|Any new sexual partners|
|Assessment of risk factors (diabetes, use of antibiotics)|
|PMH: including vaccinations|
|P Ob Hx: including prior pregnancies, pregnancy complications, gestational diabetes|
|P Gyn Hx: including abnormal Pap tests, last menstrual period, use of hormonal contraception|
|FH: including malignancies|
|SH: including tobacco, drugs, alcohol, intimate partner violence, abuse|