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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