Medicine 2 3B

Group 1A
garbage.. kung lung dse, important
ang occupation at kung saan nakatira..
kung cardio and GI, important yung
food (kasi db pag maalat or
masyadong macholesterol, factor sa
cardio yun).

GUIDELINES:

Disclaimer: not necessarily na susundin lahat. Guide lang

po ito for better output sa ating preceptorials in Medicine
2.Sundin pa din ang inyong best judgment. This is based from
Dr. Bautistas style nung med1.

I. General Data, Chief Complaint, History of

Present illness
General Data

Chief
Complaint
History of
Present
illness

Please include ALL (name, age, sex

etc.. yung typical general data of
patient na nasa checklist).

Review of
systems

If this is a neuro case, include

HANDEDNESS
You know this
According to doc Bautista, dapat brief,
chronological, and complete. Example,
3 days PTA nagstart yung chief
complaint, 2 days.. 1 day, anung
nangyaru sa patient? Or kung 1 day
PTA, hours: morning noon evening,
anung ginagawa ng patient,
pakiramdam niya? So para bang
kinukumpleto niyo yung story.. yung
progression ng symptom til admission.
Remember pag iddescribe ang
symptom: PQRST If this is PAIN,
not enough ang pain scale, at the
same time, very subjective ito.. so..
ask the patient kung nagagawa pa ba
nya yung usual na ginagawa niya, or
nakahiga nalang siya dahil sa pain.
Something like that. Same goes sa
headache.
Key here: dapat mabusisi, matanong
about the symptom. Dito palang,
mapapakita niyo na sa patient na
nagccare kayo sa kanya and the
patient would feel na super interesado
kayo sa sakit niya at sa kung paano
gagamutin yung sakit niya. Gets?

Kapag sinabi ng patient na may

diabetes siya or hypertensive, ask
lahat ng symptoms ng diabetes and
HPN Then yung ibang system,
daanan nalang.. Psych part, not really
needed.
III. Physical Examination
Dito papasok ung importance ng working diagnosis /
impression niyo about the patient. Sabi nga ni Doc
Bautista, kapag feeling mo na yun ang sakit ng patient,
dun ka magffocus sa system na yun to confirm yung
feeling mo na diagnosis. However, daanan mo pa din
ibang system.
If cardio
and/or
kidney
related dses..
If lung dses,

If neuro case,

II. Past Medical History, Family Medical History,

Social and Personal History and Review of
Systems
Past Medical
History and
Family
Medical
History
Social and
Personal
History

Ask everything.. from immunization,

past operations, diseases, medications
etc. Same with family history
No need for the house, yung structure
(siguro important lang ito kung
tatanungin niyo kung may kasama ba
sa bahay na may sakit din then if yes,
ilan kaya sila nakatira dun and ilan
kaya yung rooms? This true sa mga
infectious dse.. pag non-infectious, not
really that important..)
No need na din sa water supply,

Educational attainment, not really,

unless psych patient tayo.
In this part, according to doc bautista,
lahat ng sinabi ng patient regarding
his/her past, family Hx.. dito
macconfirm sa part na ito. Thats why
sama-sama yung past, family, ros.. so
that hindi ito maging
confusing/conflicting with HPI

If GI case,
If endo case,

MAIN FOCUS
Focus on cardio examination,
peripheral VS, Eyes (esp. fundoscopy),
kidney exam
Chest and lung examination (as in
complete: from inspection to
auscultation), lymph nodes, Throat
exam,
Complete neuro-muscular examination,
cranial nerves, HEENT, mini mental
status
If ang cause for example ay cardio in
origin (ex. Stroke 2ndary to HPN),
check HPN signs: cardio and PVS
examination etc. Same goes kapag
lung in origin like meningitis from
pneumonia, include thorough lung
examination etc
Abdominal examination
Ok.. almost all system kelangan bigyan
ng focus.. haha.

By the way, dont forget VITAL SIGNS. lagi ito.

Anyway, these are just guidelines, yung mga paulit-ulit

na sinasabi s amin ni doc bautista. Yung sa PE,
suggested main focus lang siya. Meaning, its ok na
maging mabusisi kayo sa system na yun. But this not
necessarily mean na neglected na ang ibang PE ah.
Kelangan pa din complete.. I agree dun kay doc.
Ayoko naman siyempre na magfocus kayo sa Ears

Medicine 2 3B
Group 1A
kung ang problem talaga ay nasa lungs. Right? ayun
lang
IV. Other Reminders regarding Ward Cases

Everyone is encouraged to bring your own steth

and penlight kahit hindi naka-assign sa PE, why?
Para if ever may abnormality sa lungs or heart
sounds, opportunity un na marinig ung mga
abnormalities na un. Ok ba?

Every subgroup, dapat may note taker basta

bahala na kayo mag-assign kung sino. TO THE
NOTE TAKER: transcribe your notes then
send to my email add:
kristinecaberte.29@gmail.com. Yes. Ako na
po ang magcompile lagi. Send it not later
than FRIDAY, 10PM. ILL SEND THE
COMPLETE WARD NOTES, FRIDAY, NOT
LATER THAN 12 MN.

WRITTEN REPORT: Individual Paper po ito so

bahala na po kayo sa format and content.
basta ito yung contents ng paper:
o The Patient (the case and salient
features)
o Primary impression
o DDx
o Approach to Diagnosis

Necessary lab exams for definitive

DDx
Sa DDx sa paper, not necessary na parepareho. Basta you have at least 3 DDx daw
accdg. to doc.
ORAL PRESENTATION: Powerpoint. Yung
content, same with written report
o
The Patient (the case and salient
features)
o Primary impression
o DDx
o Approach to Diagnosis
o Necessary lab exams for definitive
DDx
This time, for the oral presentation, kelangan
magmeeting tayo for our DDx. Top 3 ulit.
ayun.
So far, ito muna. yung mga meetings like for
our oral presentation, to be announced nalang.
Pero for the whole year, ito na gagawin
natin. Ok? Dont worry bout assignment sa
ward kasi magpapalit pa yan kasi bunutan
naman so mag-iiba pa yan every shifting.
Questions, suggestions, comments. Text niyo
lang ako: 0917-5247783 / 0933-1511924 or
message lang kayo sa groups natin.
Thank you!
o