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Obtain a medical history in a reproductive-aged woman

Learner Task: Take a complete history from this patient.
Educator Script: Provide the following pertinent patient history of a reproductive-aged woman with abnormal uterine bleeding as asked by the learner:

  • HPI: A 40-year-old G4P3 woman presents to your office complaining of heavy menstrual periods over past 3-6 months, and now this last period has lasted for three weeks. She denies cramps and pelvic pain. She is unsure if she has of fibroids; she has not been told she has them.
  • PMH:  None
  • PSH:  D&C 15 years ago
  • Meds: None
  • Allergies: No known drug allergies
  • P OB Hx: 3 term NSVD’s, uncomplicated, 7-8 pounds each; no miscarriages; one abortion at 10 weeks via D&C; no history of post-partum hemorrhage
  • P GYN Hx: 12/28/3-5 days, still regular cycles, but periods now lasts 7-10 days; age at first intercourse =17; number of lifetime partners=3, all men; current partner=1 for past 12 years; no history of abnormal Pap tests, last pap was >5 years ago; no history of STI’s; no difficulties with intercourse; not using any contraception
  • Social Hx: Denies tobacco, ETOH, IVDA
  • Review of Systems: She complains of weight gain of 5-8 pounds in past three months, feels more tired than usual, denies nausea, vomiting, constipation, weight loss, change in appetite, no personal history of bleeding disorders, denies breast discharge or tenderness, no headaches, no change in vision, no dry skin, no hair growth in abnormal places, no shortness of breath, no dizziness, no chest pain, no bleeding gums, no nose bleeds, no easy bruising

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
Introduces her/himself appropriately (first name, last name, medical student)
Addresses patient as per patient preference
Clarifies purpose of visit
Asks patient if she has concerns other than purpose of visit
Washes hands correctly (before touching patient)
Correctly inquires about five or more gynecologic history and sexual history elements: menarche, duration, frequency, first coitus, STIs, abnormal Pap, LMP, sexual orientation, lifetime partners, problems with intercourse, contraception
Correctly inquires about 3-6 obstetrics history elements: # of pregnancies, # of livebirths, term or preterm, mode of delivery of each, weight of each livebirth, any miscarriages or abortions, more of TOP
Obtains accurate OPQST of chief complaint. Inquires about three or more elements: 3-6 months heavy periods, three weeks of continuous vb, has not taken any medications, nothing makes it better or worse, heavy clots, changes pad every two hours, has to wear tampons and pads, never happened before
Obtains accurate ROS questions. Asks at least one question for each potential diagnosis (=7)
Obtains accurate 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 containing at least three of the following elements: gyn ca, breast ca, colon ca, thyroid dysfunction, coagulopathy
Obtains accurate social history including at least three of the following elements: smoking, alcohol use, drug use, support system, screen for domestic violence, pets