Perform a focused physical examination on a pregnant patient
Learner Task: Perform a focused physical exam on this patient.
Educator Script: Provide the following details of focused physical examination as asked by the learner:
- Vitals: temperature 98.6° F; BP 149/96; HR 86; RR 18; oxygen saturation 97%
- Height: 64 inches
- Weight: 207 pounds
- Skin: warm, dry; no rashes; no lesions.
- Abdomen: no right upper quadrant tenderness; fundus soft, midline, non-tender; fundal height 31 cm.
- Extremity exam: 3+ deep tendon reflexes, 1 beat clonus, 1+ pitting edema to mid-calf, symmetric
- Vagina: no abnormal discharge; cervix 2 cm dilated/50% effaced, soft, mid position; sutures palpable; fetal head at -2 station; no evidence of ruptured membranes
- Fetal heart tones: 140 bpm baseline; moderate variability; + accelerations; no decelerations; Category I
Educator Checklist: Physical Examination
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 | |
| Vital signs: obtains vital signs and recognizes elevated blood pressure and elevated body mass index | ||
| Abdominal examination: checks for right upper quadrant tenderness, examines fundus and fundal height | ||
| Obstetric examination: checks fetal lie, presence of fetal heart tones | ||
| Extremity examination: checks for edema | ||
| Neurologic examination: checks reflexes, checks for clonus, recognizes abnormalities | ||
| Pelvic examination: performs external genital examination during group B beta streptococcus collection, examines cervix |