Standardized Patient Case and Instructions to Medical Students for Two Encounters

Standardized Patient Case
Ms. Lasco was described as a “30-ish” divorced woman with an 8-year-old daughter and the chief complaint of right lower abdominal pain of 2 days' duration with nausea, cramping, but no vomiting, no dysuria, and no interruption in bowel function. Her last menses occurred 35 days ago (28-day cycle), and she was sexually active with a new partner and using no contraception due to “infrequent” intercourse. The patient's past medical history was significant for migraines and Irritable Bowel Syndrome, both beginning during her mid-twenties.
The patient's psychosocial history revealed that she grew up in a small town in New Mexico and that her mother died when she was 7 years old. After graduating from high school, Ms. Lasco received 2 years of community college training and she now is employed as a secretary at an insurance company office in Albuquerque. She was married for 3 years and divorced shortly after her daughter was born. Ms. Lasco has “always” remained close to her father, age 64, and older brother, age 36. She gets regular exercise but eats irregularly, snacking mostly on sugars and fats. She drinks “2 beers” on the weekends and has smoked 1 pack of cigarettes per day for 15 years. The family history revealed only that the patient's mother died of leukemia in her mid-thirties, and her maternal grandmother had hypertension and coronary artery disease.
After obtaining the history, students were expected to conduct a physical examination. Ms. Lasco was in apparent pain, was unable to sit or walk comfortably, and seemed frightened. She had an elevated temperature (102.5 degrees F) and heart rate (96 beats per minute). She had hypoactive bowel sounds with marked rebound tenderness and right lower quadrant pain. No masses were palpable. When students indicated that they “would” perform a pelvic examination in a real patient evaluation, they were given a note indicating that the exam would reveal the following abnormalities: a “creamy” vaginal discharge with copious bleeding; cervical motion tenderness (right greater than left); symmetrical but tender ovaries; and right adnexa “fullness” but no mass.
Initial Encounter: Obtaining a focused history and physical
Students were asked to perform a focused history and physical. The patient was described only as a 34-year-old woman who had come to the OB-GYN clinic with the complaint of right lower abdominal pain.
Students were given 25 minutes for this portion of the assessment. They were instructed to leave the room at the conclusion of the patient encounter. Students were then given 25 minutes more to write up their findings in a standard “Progress Note” format.
Second Encounter: Obtaining informed consent or refusal for an HIV test
Students were given instructions indicating that “after considering the information you obtained in the H&P with Ms. Lasco, you have decided that it is clinically appropriate to obtain an HIV test because of her history of unprotected sex with a new partner.”
Students were given 10 minutes to speak with her a second time. The students were informed that the 3 goals of this interaction were to:
1) speak with the patient about the value of the HIV test in this situation;
2) obtain informed consent or refusal for the test; and
3) answer any questions she may have about confidentiality safeguards related to the test.