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|