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UST FACULTY OF MEDICINE & SURGERY

Department of Medicine
Medicine I
Medical History and Physical Examination Grading Sheet
1 | P a g e inv 6-7-12



STUDENTS NAME ALBANO, AMD Subsection A1 Facilitator: Dra. Asis/Dra. Mercado Date September 9, 2014

TOPIC: ( / ) GENERAL ( ) Cardiology ( ) Pulmonology ( ) Gastroenterology ( ) Endocrinology
( ) Infectious ( ) Hematology ( ) Oncology ( ) Rheumatology ( ) Nephrology

( / ) Original manuscript ( ) 1
ST
Revision ( ) 2
nd
Revision

1. HISTORY TAKING
44 points

Informant/s: (patient himself) Reliability (%): 95%
Date admitted in USTH: September 8, 2014, 8:00pm Date of Interview: September 9, 2014, 2:30pm
General Data:

Name: Francisco Cuyones
Age: 43yo
Sex: M
Address: Quezon City
Civil Status: Married
Birthday: September 11, 1970
Birthplace: Quezon City
Race: Filipino
Religion: Catholic
Educational Attainment: 2
nd
yr HS
Occupation: Van driver
Contact Number: 09228409235

a. General Data 4
Complete,
Contains all pertinent data : patient
initials, age/gender, date of birth, civil
status, nationality, religion, education,
occupation, address, contact number
3 2
Some data are missing
1
Grossly lacking
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
Chief Complaint/s:

The patients chief complaint is fever.

b. Chief Complaint/s 4
Accurate and consistent with the HPI;
correctly interpreted; State in actual
language used & enclose English
equivalent/translation
3 2 1
Acceptable but needs
improvement; inconsistent
with HPI
0
No chief complaint

__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
History of Present Illness:

Patient was apparently well until 4 days ago when the fever developed. It was of sudden onset, intermittent in
nature and low grade (38.5C). It was not aggravated by any factor and was not associated with any manifestation.
Patient self-medicated with paracetamol (500mg) every 4 hours. This was started last Friday (September 5, 2014) and
ended yesterday (September 8, 2014). Fever was persistent which triggered the patient to seek consult. Laboratory
works showed an increase in creatinine level hence admission.

c. History of Present
Illness
12 11 10 9
Written in chronological order;
Symptoms are described according to
onset, location, duration, character,
aggravating or associated factors,
relieving factors, temporal factors and
severity. It includes previous work ups,
diagnosis and treatment if any
(medications- brand name /generics,
dosage, frequency, compliance) and
effect on patients condition if any.
Contains pertinent negatives.
8 7 6 5
Written chronologically,
principal symptoms are
described but some data are
lacking. Mentioned some
pertinent negatives. Included
some irrelevant data. Started
HPI with unconfirmed
diagnosis
4 3 2 1
Not written
chronologically, many
data are lacking, not
enough to arrive at a
diagnosis
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
Past (Medical) History:

Patient claims to have had no significant childhood/adult illness or hospitalizations and has not undergone any
surgery and transfusion. He claims to have complete immunizations. Patient is allergic to alcohol. He has good nutrition
UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I
Medical History and Physical Examination Grading Sheet
2 | P a g e inv 6-7-12

status & no abnormal sleep pattern (sleeps 6-8hours at night with no difficulty). Patient is not active in any exercise
routine. He is not smoking or drinking alcohol.
In 2011, patient decided to undergo a general check-up. He was then diagnosed with hypertension and
diabetes. These eventually affected his kidneys. Since then, he was advised to have his lipid profile, blood sugar and
creatinine levels regularly checked. He was prescribed the following drugs: diltiazem (300mg, once a day) for his
hypertension, sodium bicarbonate (unrecalled dosage) for his kidneys, and an unrecalled medication for his diabetes.
Patient is compliant with these medications.
Patient was involved in a motorcycle accident, year 2013, to which no major procedures were done to him.

d. Past (Medical) History 8 7 6
Complete
Contains previous childhood (if
needed) and adult medical and surgical
illnesses and hospitalizations; contains
obstetric/gynecologic history if needed
Previous health care including
immunizations; current health risk
factors -smoking-alcohol-illicit drug
use; allergies; medications
5 4 3
Some important data are
missing. Included data that
should be in the HPI.
21
Grossly lacking.
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
Family History:

The patients father at the age of 75 passed away 8 years ago due to bone cancer. His mother, 70 years old,
and two siblings (37 years old and 40 years old) are all healthy, although his mother is also hypertensive and diabetic.
Patient noted that diabetes runs in their family.

e. Family History 4
Contains the genetic disorders and
major health conditions in the family;
Identified specific family members
32
Some important data are
missing.
1
Grossly lacking.
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
Personal/Social History:

Patient is married to a 40 yo nurse aid at USTH. They have 4 off-springs aged 19, 18, 16 and 14 (all are
attending school. The family is intact and living harmoniously in a concrete housing. The patients mother and a pet cat
live with them. Financial support comes from his work as a van driver (UV Express) and his wifes work. There are no
other job histories available. Patient seldom has sexual contact with his wife. He didnt have any other sexual partners
besides his wife. No significant life event/s noted.

f. Personal/Social History 4
Describes the cultural background,
family structure & relationships, stress
factors, educational data, economic
status; environmental data;
occupational history; dietary history.
32
Some important data are
missing.
1
Grossly lacking.
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
Review of Systems:

General Constitutional Symptoms: (-) pain, fever, chills, malaise, easy fatigability, changes in sleep pattern, changes in
appetite, changes in weight
Skin/Hair/Nails: (-) rush/eruptions, itching, pigmentation or texture changes, excessive sweating, alopecia, abnormal
growth
Head and Neck: (-) headache, dizziness, head injuries, loss of consciousness, abnormal throat conditions; (+) blurring of
vision, right ear hearing loss, frequent colds
Lymph nodes: (-) enlargement, pain, suppuration
Respiratory: (-) dyspnea, pain related to respiration, cyanosis, wheezing, sputum, cough, hemoptysis, night sweats
Cardiovascular: (-) chest pain, palpitations, dyspnea, orthopnea, edema; (+) easy fatigability, hypertension (usual BP
range of 140/100) mmHg
Gastrointestinal: (-) changes in appetite, hematemesis, abdominal pain, dysphagia, heartburn, nausea, vomiting,
diarrhea, constipation, intolerance to any class of food, flatulence, hemorrhoids, jaundice, changes in stool
color/contents
Genitourinary: (-) dysuria, hematuria, nocturia, polyuria, oliguria, discharge, anuria, weak urinary stream, urinary
incontinence, passage of bubbly/sandy urine
Hematologic: (-) anemia, pallor, easy fatigability
Endocrine: (-) thyroid enlargement, heat/cold intolerance, unexplained weight change, poly-dypsia/phagia/uria
Musculoskeletal: (-) joint stiffness, pain, restriction of motion, deformity
Neurologic: (-) weakness, paralysis, abnormalities in sensation, seizures, syncope, tremors, loss of memory, inability to
concentrate, abnormalities in coordination
Psychiatric: (-) depression, mood changes, anxiety, agitation, tension, suicidal thoughts, irritability
UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I
Medical History and Physical Examination Grading Sheet
3 | P a g e inv 6-7-12


g. Review of Systems 8 7 6
Complete.
Reviewed general and overall trends
per system. Does not repeat data
stated in the HPI
5 4 3
Some important data are
missing. Repeated data
already stated in HPI.
2 1
Grossly lacking.
__ No need to rewrite

__ Need to rewrite.
Take note of the
corrections
BONUS POINTS (1-2 pts):
1. Excellent narration/description of the clinical history
2. Observed correct grammar and syntax



FINAL
DISPOSITION:
(Please check
appropriate box)

Very good history. No need to
rewrite.

Rewrite only the
indicated part of the medical
history & P.E and re-submit
ASAP on _____________
together with the initial
manuscript.

Rewrite the
entire History & PE;
and re-submit ASAP
on _____________
together with the initial
manuscript.


History (44) _______
P.E. (50) _______
S.F. (03) _______
O.S.I. (03) _______
Total (100): ____
FINAL GRADE:


Submitted by: Date submitted: _______________



Facilitator ____________________________ Date: ___________
Signature over printed name
%