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Take a complete history from this patient

Learner Task: Obtain a complete history from this patient.
Educator Script: Provide the following patient history as asked by the learner:

  • HPI: She is feeling well and experiences positive fetal movement. Her pregnancy was complicated by advanced maternal age, grand multiparity, obesity, and diet controlled gestational diabetes.
  • PMH: HTN (no meds); AMA; obesity (pre-pregnancy height/weight was 64”/207 pounds)
  • PSH: none
  • P Ob Hx: 5 vaginal deliveries; 1 preterm due to hypertension; 1 spontaneous abortion
  • P Gyn Hx: no abnormal Pap tests; last Pap test 2 years ago; no sexually transmitted diseases; no endometriosis/fibroids; monthly menstrual cycles lasting 5 days
  • Medicines: none
  • Allergies: none
  • SH: no tobacco; no alcohol; married
  • FH: non-contributory
  • Review of systems: fatigued; no bleeding since delivery; denies skin changes/hair changes; no depression; no vaginal bleeding; no regular contractions; denies headaches, visual changes, epigastric pain; minimal symmetric lower extremity edema.

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
Introduces her/himself appropriately (first name, last name, medical student)
Addresses patient as per patient preference
Clarifies purpose of visit, asks if patient has any other concerns
Washes hands correctly (before touching patient), uses sterile technique throughout visit
Obtains accurate obstetric history: number of deliveries, mode of delivery, gestational ages, any complications
Obtains accurate gynecologic history: menarche/duration/frequency, first coitus, STIs, abnormal Pap tests, gynecologic surgery or problems, sexual orientation, lifetime partners, problems with intercourse
Obtains accurate review of systems for chief complaint: typical pregnancy symptoms, contractions, leaking fluid, bleeding, fetal movement. Also includes the following pertinent review of systems: headache, edema, RUQ or epigastric pain, visual changes
Obtains accurate past medical history
Obtains accurate surgical history
Obtains accurate medication use, asks about over the counter and herbal supplements
Obtains accurate allergy history (ideally about food allergies, too)
Obtains accurate family history
Obtains accurate social history including smoking, alcohol use, drug use