| | 14 Case 14 scenario (prenatal visit)
Doorway information about patient
The patient is a 24-year-old woman who comes to the office for an initial prenatal visit
Vital signs
. Temperature : 37.1’C(98.8F)
. Blood pressure : 120/75 mmHg
. Pulse : 78/min
. Respirations : 20/min
—————
Case 14 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 25-year-old woman here for your first prenatal visit
. This is your first pregnancy (no prior miscarriage or abortion)
. Last menstrual period 12 weeks ago
. Positive home pregnancy test 6 weeks ago
. Have not felt any fetal movements yet
. Menarche at age 13 ; periods usually regular every 28-30 days with bleeding 4-5 days each month
. No morning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet
Past medical history
. No prior medical problems
. No surgeries or hospitalizations
. Medications : None
. Medication allergies : None
. Up to date on all standard adult immunizations
. Immediate family members are all healthy
. Occupation : Homemaker
. Married , lived with husband
. Tobacco 1 pack a day for 5 years
. Alcohol : 1-3 beers a week for 3 years
. Recreational drugs : None
Physical examination
HEENT
. PERRLA, EOMI
. Oropharynx clear
Lungs :
. Clear to auscultation bilaterally
Heart :
. Regular rate and rhythm without murmurs, gallops , or rubs
Abdomen :
. Non-tender , Non-distended
. Normative bowel sounds throughout
. No hepatopslenomegaly
. No bruits
Extremities
. No cyanosis or edema
—————
Case 14 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about LMP
. Asked about how you first suspected and confirmed pregnancy
. Asked about obstetrical / reproductive history (pregnancy and abortions)
. Asked about gynecologic history (menarche, regular periods , contraception)
. Asked about any pregnancy -related problems (vomiting , fever , abdominal pain, vaginal bleeding)
. Asked about diet , appetite , and weight gain
. Asked about genitourinary symptoms (eg , discharge, lesions, dysuria)
. Asked about sleep
Past medical /family/social history
. Asked about past medical issues (especially heart conditions , autoimmune disorders , hypertension , diabetes , sexually transmitted infections ,ad n renal disease)
. Asked about previous blood transfusions
. Asked bit current medications
. Asked about medication allergies
. Asked about exposure to cats
. Asked about rubella immunization in the past
. Asked about family health (congenital or birth problems in the family)
. Asked about tobacco , alcohol , and drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes (for pallor)
. Examined oral cavity (for general hygiene)
. Examined legs (for edema and varicose viens)
. Auscultated heart and lungs
. Examined and auscultated abdomen (if <28 weeks of fundal grip ; if > 28 weeks do Leopold maneuvers)
Counseling
. Explained physical findings
. Discussed appropriate prenatal tests
. Advised you to stop usage of tobacco and alcohol
. Advised safe sexual practices
. Explained the need for prenatal vitamins , iron supplementation , and nutritious diet
. Explained the importance of regular antenatal visits
Communication skills and professional conduct
. Knocked before entering the room
. introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Diagnostic study/studies
. RH(D) blood type , antibody screen
. CBC (hemoglobin /hematocrit , MCV)
. HIV , VDRL/RPR, HBsAg
. Rubella and varicella titers
. Pelvic examination (with Pap test, if indicated)
. Chlamydia PCR
. Urinalysis and culture
—————
Case 14 clinical summary
Clinical Skills Evaluation
Case 14 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 24-yo woman , G1P0A0 and LMP 12 weeks ago , who presents for her first prenatal visit.
. No fetal movements yet.
ROS : No mooning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : parents and siblings are healthy
SHx : 1 PPD smoker for 5 years , 1-3 beers/ week fro 3 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
.Vital signs ; temperature , 37.1 ‘C (98.8F) ; blood pressure , 120/75 mmHg ; pulse , 78 /min; and respirations , 20/min
. HEENT : PERRLA < EOMI , no jaundice , oropharynx clear
. Lungs : Clear to auscultation bilaterally
. Heart : RRR without murmurs, gallops , or rubs
. Abdomen : Non-tender , non-distended , normative bowel sounds throughout ; no hepatosplenomegaly ; no bruits
. Extremities : No cyanosis or edema
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Normal pregnancy
History finding(s)
. LMP 12 weeks ago
. Home pregnancy test positive 6 weeks ago
Physical examination finding(s)
. non-distended abdomen
. No edema
Diagnostic studies
. Rh(D)type , antibody screen
. CBC
. HIV, VDRL/RPR , HBsAg
. Rubella and varicella titers
. Pelvic examination
. Chlamydia PCR
. Urinalysis and culture
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2018/08/15 03:31pm 
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