UST FACULTY OF MEDICINE & SURGERY

Department of Medicine
Medicine I
The Patient Write-Up

STUDENT’S NAME MCS Subsection D5 Facilitator: Dr. Arl Ann M. Manzo Date: September 2018

Topic / Organ-System: ( X ) GENERAL ( ) Cardiology ( ) Pulmonology ( ) Gastroenterology ( ) Endocrinology

( X ) Infectious ( ) Hematology ( ) Oncology ( ) Rheumatology ( ) Nephrology
( X ) Original manuscript ( ) 1ST Revision ( ) 2nd Revision

HISTORY TAKING
44 points
1. General Data / Patient Information:
Name (initials only): C.M.M. Age: 68 yrs old Gender: Female
Birthday/Birthplace: October 7, 1949 Clarin, Bohol Nationality/Citizenship: Filipino Religion: Roman Catholic
Educational attainment: 1st year high school Civil Status: Married
Occupation: None
Home Address: Cristobal Street, Sampaloc, Manila
Provincial address: Clarin, Bohol
Informant/s (relationship): Patient and Son Reliability (%): 65% and 85%, respectively
Date admitted in USTH: August 28, 2018 Date of Interview: August 30, 2018
General Data 4 3…2 1 __ No need to rewrite
Complete, Some data are missing Grossly lacking
Contains all pertinent data : patient __ Rewrite & take
initials, age/gender, date of birth, civil note of corrections
status, nationality, religion, education,
occupation, address, contact number
2. Chief Complaint/s: fever (“nilalagnat”)

Chief Complaint/s 4 3…2…1 0 __ No need to rewrite

Accurate and consistent with the HPI; Acceptable but needs No chief complaint
correctly interpreted; State in actual improvement; inconsistent __ Rewrite & take
language used & enclose English with HPI note of corrections
equivalent/translation
3. History of Present Illness (HPI):
Two weeks prior to admission, patient waded into floods noting that she had pedicure done a week before.

One week prior to admission, patient claimed to have a week-long of intermittent fever which she described
as fluctuating in the afternoon (“pinakamainit tuwing hapon”). Fever was accompanied with joint pains in
the hips and knees graded as 5/10 which was unrelieved by 2 tablets of 10mg/2 mg/500 mg Phenylephrine
HCl Ibuprofen (Bioflu) taken twice daily for a week although had no coughs nor colds.

Few hours prior to admission, noticing that her skin was has already turned yellowish and sclera is already
reddish, she was taken to a healthcare center at Quintos Street Manila for check-up where she was advised
to go to Perpetual Hospital to have laboratory examinations and upon consultation, the attending physician
diagnosed her of having leptospirosis and urinary tract infection and advised her to be admitted in the UST
hospital.
History of Present Illness 12 … 11 … 10 … 9 8 … 7… 6 … 5 4…3…2…1 __ No need to rewrite
Written in chronological order; Written chronologically, Not written
Symptoms are described according to principal symptoms are chronologically, many __ Rewrite & take
onset, location, duration, character, described but some data are data are lacking, not note of corrections
aggravating or associated factors, lacking. Mentioned some enough to arrive at a
relieving factors, temporal factors and pertinent negatives. Included diagnosis
severity. It includes previous work ups, some irrelevant data. Started
diagnosis and treatment if any HPI with unconfirmed
(medications- brand name /generics, diagnosis
dosage, frequency, compliance) and
effect on patient’s condition if any.
Contains pertinent negatives.
4. Review of Systems:
General:
(-) weight loss
Skin/Hair/Nails:
(-) itchiness, (+)color change, (-)hyperpigmentation/hypopigmentation/ rash/ vasomotor changes/texture
changes/change in the hair/photosensitivity/abnormal nail growth/ abnormal nail color/mole change/excessive
sweating
Eye:
(+) blurring of vision, (-)photophobia/doubling of vision,(+)redness, (-)itchiness/pain/lacrimation
Ear:

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I
The Patient Write-Up
(-) deafness/tinnitus/discharge/otalgia
Nose:
(-) epistaxis/discharge/obstruction/abnormal sense of smell/post-nasal drip/sinus pain
Mouth:
(-) bleeding gums/sore/fissure/tongue abnormality/dental pain/disturbance of taste (metallic)
Throat:
(-) soreness/tonsillar pain/hoarseness or change in voice
Neck:
(-) stiffness/limitation of motion/mass/sensation of lump in the throat
Breast:
(-)mass/discharge/change in the color of the areola/ tenderness/trauma/ skin change/skin
dimpling/galactorrhea
Pulmonary:
(-) dyspnea /shortness of breath/ cough/ sputum production/ hemoptysis /cyanosis/ wheezing /chest pain
related to respiration/ backpain / chest wall abnormality

Cardiac:
(-) chest pain/easy fatigability/palpitations/leg edema
Gastrointestinal:
(-)nausea/vomiting/retching/hematemesis/melena/hematochezia/dysphagia/belching/ indigestion/food
tolerance/ heartburn/flatulence/abdominal pain/ abdominal distention/diarrhea/ constipation/anal
lesion/abdominal mass/hemorrhoids/change in stool color or content/jaundice
Genitourinary:
(+)weak urinary stream, (-)urinary inconsistency/dysuria/hematuria/nocturia/polyuria/ oliguria/anuria
Musculoskeletal:
(+) joint stiffness, (+)pain, (-)swelling, (+)muscle pain, (-)cramps/muscle weakness/muscle wasting
Neurologic:
(-) seizure, loss of consciousness/abnormality of sensation/motor dysfunction/ abnormality of
coordination/speech disturbances/mental change/ head trauma/tremors/ loss of memory
Vascular:
(-) phlebitis, variceal pain, variceal swelling, claudication, leg discoloration, extremity temperature
change(coldness/warmness)
Endocrine:
(-) heat-cold intolerance, palpitations, breast change, voice change, polydipsia, polyphagia, polyuria, irritability,
slowness in mentation, distribution and changes in facial or body hair, increased hat or glove size
Hematologic:
(-) abnormal bleeding/ bruising/ pallor/ adenopathy
Psychiatric:
(-) anxiety/depression/ hallucination/delusion/paranoia/ violent behavior/ mood

Review of Systems 8…7…6 5…4…3 2 … 1… 0 __ No need to rewrite

Complete. Some important data are Grossly lacking.
Reviewed general and overall trends missing. Repeated data __ Rewrite & take
per system. Does not repeat data already stated in HPI. note of corrections
stated in the HPI
5. Past History:
Birth and Developmental History: no medical issues
Childhood illness/hospitalization: undergone cataract surgery but year was unrecalled
Surgeries: None
Injuries/Accidents: None
Transfusions: None
Allergies:
a. Non-Drug: None
b. Drug-related: None
Obstetric/Gynecologic History: G10P8
Past (Medical) History 4 3…2….1….. 0 __ No need to rewrite
Complete Some important data are Grossly lacking.
Contains previous childhood (if missing. Included data that __ Rewrite & take
needed) and adult medical and surgical should be in the HPI. note of corrections
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
6. Current Health Status/Risk Factors

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I
The Patient Write-Up
Health screening: laboratory examinations were done few hours PTA at Perpetual Hospital
Nutrition/Dietary Habits: eats 3x/day; eats fruit(banana) daily
Sleep Pattern: 7-8 hours per day
Exercise: sedentary- watering of plants
Smoking: not a smoker
Alcohol: stopped drinking within the year 2018
Environmental Exposure: stated that she has waded into floods many times before due to constant flooding within
their area
Medications: no known maintenance medications PTA
a. Self-prescribed/OTC drugs:
b. Doctor-prescribed drug/s:
c. Herbal medication/s:
d. Allergies to drug:
Illegal Drug/Substance use:
Immunizations: none
Current Health Status/Risk 4 3…2…1 0 __ No need to rewrite
Factors Accurate and completely; correctly Acceptable but needs Grossly lacking
interpreted; improvement; __ Rewrite & take
note of corrections
7. Family History:
Current health conditions of parents, sibling, children: Lives with second husband and 2 children.
Determine pattern of disease within a family:
Death, cause, date, and ages at death: had two miscarriages

Family History 4 3…2 1… 0 __ No need to rewrite

Contains the genetic disorders and Some important data are Grossly lacking.
major health conditions in the family; missing. __ Rewrite & take
Identified specific family members note of corrections
8. Personal & Social History:
Marital Status: married
Where patient was born and raised and by whom? Living arrangements and conditions/ Family structure and
background/ How are things at home? Interpersonal relationship with family and peer group : Born and raised in
Clarin, Bohol with 2 male siblings and has lived in Manila since 1964. Patient now lives with 4th child, Marni, who was
also the other informant during the interview. Patient’s other children have their own families already and have been
living separately.
Employment history/Job satisfaction: a housewife
Significant life events, deaths, divorce, financial hardships: Patient was married to first husband with whom he had 4
children. Patient was living with second husband with whom she has six children, 5 alive.

Personal/Social History 4 3…2 1…0 __ No need to rewrite

Describes the cultural background, Some important data are Grossly lacking.
family structure & relationships, stress missing. __ Rewrite & take
factors, educational data, economic note of corrections
status; environmental data;
occupational history; dietary history.
BONUS POINTS: 1. Excellent narration/description of the clinical history
(1 - 2 pts) 2. Observed correct grammar and syntax

History (44) _______

Very good history. No need to Rewrite only the part of Rewrite the
rewrite. the medical history & P.E with entire history & PE; P.E. (50) _______
corrections and re-submit on re-submit on _______
_____________ together with together with the initial S.F. (03) _______
FINAL
the initial manuscript. manuscript. O.S.I. (01) _______
DISPOSITION:
Dx (02) _______
(Please check
appropriate box) Total (100): ____
FINAL GRADE:
%

Submitted by: Date submitted: __September 7, 2018__

1.Sibulo, Madeline C.

Facilitator ___Arl Ann M. Manzo, M.D.___ Date: ___________

Signature over printed name

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