UST FACULTY OF MEDICINE & SURGERY

Department of Medicine
Medicine I

Student’s name: Dan Angelo Matias Subsection: C4 Facilitator: Dr. Ong Date: August 19, 2019
Topic / Organ-System:
( ) GENERAL ( ) Cardiology ( ) Pulmonology ( ) Gastroenterology ( ) Endocrinology
( ) Infectious ( ) Hematology ( ) Oncology ( ) Rheumatology ( ) Nephrology
( ) Original manuscript ( ) 1ST Revision ( ) 2nd Revision
HISTORY TAKING
44 points
1. General Data/Information:
Name (initials only): SMT Age: 57 Gender: Female
Birthday/Birthplace: December 25, 1961 Nationality/Citizenship: Filipino
Educational attainment: Secretarial course Civil Status: Widow (Unmarried)
Occupation: Housewife Religion: Roman Catholic
Home Address: 1-300 B Lallana St., Tondo, Manila
Provincial address: N/A
Informant/s (relationship): Patient Reliability: Good
Date admitted in USTH: August 17, 2019 Date of Interview: August 19, 2019
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: Vomiting

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:
Six weeks PTA, patient experienced burning epigastric pain, non-radiating graded 8/10 lasting for 30
minutes which was aggravated by eating and not relieved by intake of food. Pain was relieved upon taking
Kremil-S. This is accompanied by foul smelling black stools that are hard in consistency. The patient also had
an episode of vomiting amounting to half a cup and and is characterized as “coffee-ground”. Patient denied
other accompanying symptoms. Patient sought medical consult and was subsequently admitted in Tondo
Medical Center.
Five weeks PTA, she was discharged after a one-week hospital confinement with relief of symptoms.
Five days PTA, there was resumption of burning epigastric pain, non-radiating graded 8/10 lasting for
30 minutes and was described as “maasim”, and melena amounting to one episode per day. The patient also
experienced generalized body weakness. Patient returned to the same hospital for consult and she was
advised to undergo upper gastrointestinal endoscopy in other facilities due to lack of facilities.
One day PTA, patient consulted at Jose Reyes Memorial Medical Center OPD. She was then scheduled
for Endoscopy on August 1, 2019 and prescribed with an unrecalled dose of omeprazole.
Few hours PTA, patient still experienced melena, epigastric pain non radiating graded 8/10 and now
accompanied with 2 episodes of black colored vomit amounting to 1 handful each which prompted consult
at the USTH-ERCD and subsequent admission.

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 Survey: (+) weight loss (since 3 months prior), (+) loss of appetite
Cutaneous: (-) petechiae, (-) rashes, (-) pruritus, (-) skin discoloration
Eye: (-) blurring of vision, (-) eye pain, (-) eye discharge

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I

Ear: (-) deafness, (-) congestion, (-) otalgia

Nose: (-) epistaxis
Mouth: (-) bleeding gums, (+) altered taste
Pulmonary: (-) dyspnea, (-) shortness of breath, (-) hemoptysis (+) cough (-) colds
Cardiology: (-) chest pain, (-) cyanosis, (-) edema, (-) syncope, (-) leg edema
Genitourinary: (+) nocturia, (-) urgency, (+) frequency, (-) hesitancy, (-) weak urinary stream, (-) urinary
incontinence, (-) dysuria, (-) hematuria, (-) perineal pain
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat/cold intolerance, (-) palpitations
Neurologic: (-) loss of consciousness, (+) weakness
Psychiatry: (-) change of behavior, (-) insomnia
Musculoskeletal: (-) muscle pain, (-) joint pain hands
Hematologic: (+) easy fatigability, (-) easy bruisability, (+) pallor, (-) bleeding
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 Some important data are
missing. Included data that
should be in the HPI.
5. Past History:
Previous illness/hospitalizations:
Tondo Medical Center (07/08-15/19) – Upper GI bleeding secondary to NSAID gastropathy
Previous Surgeries: none
Previous blood transfusions: --
Allergies: --
Previous accidents: --
Adult Immunization: Unrecalled vaccination
Current medications: none
Past 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 should be in the HPI. note of corrections
surgical illnesses and hospitalizations;
contains obstetric/gynecologic history if
needed
6. Current Health Status/ Risk Factors:
Health screening:
Nutrition/dietary habits:
Sleep pattern: generally normal
Exercise: none
Smoking: none
Alcohol intake: none
Environmental exposures: none
Medication data: NSAID (mefenamic acid) and antacid (Kremil-S) for the last 3 months

Immunization history: Vaccinated, unrecalled vaccination

Current Health Status/Risk Factors
4 3…2 1…0 __ No need to rewrite
Health screening, nutrition/dietary Some important data are Grossly lacking.
habits, sleep pattern, exercise, missing. __ Rewrite & take
smoking, alcohol, environmental note of corrections
exposures, medication data,
immunizations.

7. Family History:
(-) HTN- father and mother (unrecalled cause of death)
(-) DM- father and mother (unrecalled cause of death)
(+) HTN- brother
(+) Neck cancer- husband
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: Widowed in 2009 from live in partner

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I

Family structure: Lives at home with grandson/granddaughter

Personal/Social History 4 3…2 2 … 1… 0 __ No need to rewrite
Describes marital status, the family, Some important data are Grossly lacking.
and cultural, and economic missing __ Rewrite & take
background, family structure & note of corrections
relationships, stress factors,
environmental data, occupational
history, sexual history
BONUS POINTS: 1. Excellent narration/description of the clinical history
(1 - 2 pts) 2. Observed correct grammar and syntax

PHYSICAL Date of patient’s confinement at USTH-CD or consultation at OPD: August 17, 2019
EXAMINATION
50 points Date PE was done by the medical student: August 19, 2019

1. General Survey:
Patient is conscious, coherent, thin, pale, not in cardiorespiratory distress
General Survey 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate general survey. Findings are missing. __ Rewrite & take
adequately described note of corrections
2. Vital Signs:
Blood pressure: 110/70
Heart rate: 120/min
Respiratory rate: 22/min
Temperature: 36.7 deg Celsius
Height: 147 cm
Weight: 50 kg
BMI: 23.1 kg/m2
4 3…2 1…0 __ No need to rewrite
Able to include complete and accurate Some important data are Grossly lacking.
vital signs. Findings are adequately missing. __ Rewrite & take
described. Anthropometric data note of corrections
reported.
3. Skin:
(+) pallor, warm and dry skin, poor skin turgor, (-) cyanosis, (-) jaundice
Skin 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate skin examination. Findings missing. Pertinent negative __ Rewrite & take
are adequately described. Pictures of findings are stated but not note of corrections
lesions included (w/ patient’s consent.) complete
4. HEENT/Neck: n/a
Did not perform
HEENT/Neck 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate HEENT & Neck examination. missing. Pertinent negative __ Rewrite & take
Findings are adequately described; findings are stated but not note of corrections
Thyroid described. complete
5. Thorax/Breast/Lungs: n/a
Did not perform
Thorax/Breast/Lungs 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate thorax, breast and pulmonary missing. Sequence of __ Rewrite & take
examination. Findings are adequately physical exam is correct. note of corrections
described. Followed the method of Pertinent negative findings
physical examination in correct are stated but not complete
sequence: Inspection, palpation,
percussion, auscultation; included
pertinent negative findings needed for
diagnosis. May include breast
examination if needed.
Lung Auscultogram:
Did not perform
Lung Auscultogram 4 3…2 1…0 __ No need to rewrite
Able to accurately illustrate the lung Some important data are Grossly lacking.
findings in the prescribed missing. Not done __ Rewrite & take
auscultogram form note of corrections

6. Cardiovascular: (Describe findings adequately. Observe correct sequence i.e. “I - P - A”. State pertinent negatives).
Did not perform
Cardiovascular 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate cardiovascular examination. missing. Sequence of

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I
Findings are adequately described. physical exam is correct. __ Rewrite & take
Followed the method of physical Pertinent negative findings note of corrections
examination in correct sequence: are stated but not complete
Inspection, palpation, auscultation;
included pertinent negative findings
needed for diagnosis
Heart Auscultogram:
Did not perform
Heart Auscultogram 4 3…2 1…0 __ No need to rewrite
Able to draw, report completely and Some important data are Grossly lacking.
accurately cardiovascular findings in missing. Not done __ Rewrite & take
the prescribed auscultogram form to note of corrections
include JVP & CAP
7. Gastrointestinal:
flat, no visible pulsation or peristalsis, no scars, no skin discoloration, inverted umbilicus, normoactive bowel
sounds, dull, (-) abdominal mass, (-) direct (-) rebound tenderness
Gastrointestinal / Rectal 5…4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate GI examination. Findings are missing. Sequence of __ Rewrite & take
adequately described. Followed the physical exam is correct. note of corrections
method of physical examination in Pertinent negative findings
correct sequence: Inspection, are stated but not complete
auscultation, percussion and palpation;
included pertinent negative findings
needed for diagnosis; Included rectal
examination if necessary; Reported
and done properly.
8. Genitourinary:
Did not perform
Genitourinary 3 2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate genitourinary examination. missing. Sequence of __ Rewrite & take
Findings are adequately described. physical exam is correct. note of corrections
Pertinent negative findings
are stated but not complete
9. Musculoskeletal:
Did not perform
Musculoskeletal 3 2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate musculoskeletal missing. Sequence of __ Rewrite & take
examination. Findings are adequately physical exam is correct. note of corrections
described Pertinent negative findings
are stated but not complete
10. Extremities:
Did not perform
Extremities 3 2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate examination of the missing. Pertinent negative __ Rewrite & take
extremities. Findings are adequately findings are stated but not note of corrections
described complete
11. Neurological:
Did not perform
Neurological 4 3…2 1…0 __ No need to rewrite
Able to include a complete and Some important data are Grossly lacking.
accurate neurological examination. missing. Sequence of Not attempted even if __ Rewrite & take
Findings are adequately described. physical exam is correct. some findings may be note of corrections
Sequence of physical exam is correct. Pertinent negative findings contributory to
Pertinent negative findings are are stated but not complete diagnosis
complete. Basic neuro exam done.

SALIENT FEATURES (SF): Subjective Pertinent Positives Subjective Pertinent Negatives

3 points ● 57 y/o ● No fever
● General weakness ● No vision changes
● 8/10 localized epigastric pain ● No shortness of breath
● Nausea and vomiting ● No chest pain
● Melena
● (+) Weight loss
● (+) Loss of appetite
● (+) Malaise
● (+) Headache
Objective Pertinent Positives Objective Pertinent Negatives
● (+) Pallor ● Normal Vital Signs

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine I

● (+) Pale palpebral conjunctiva ● Conscious, coherent

● No leg edema
● BP:110/70
● Normoactive bowel sounds
Salient features 3 2 1…0 __ No need to
Able to include pertinent Some pertinent Grossly lacking. rewrite
positive & negative data positive & negative
needed to arrive at a data are missing. __ Rewrite &
certain initial Included some data take note of
impression/assessment of which are not salient corrections
the problem.
Organ-System Gastrointestinal
involvement (OSI):
3 points
Organ-system 3 2 1…0 __ No need to
involvement Able to identify the Incorrect but may be No organ rewrite
organs/system/s involved in acceptable based on system
the patient’s pathologic the collected data or identified __ Rewrite &
process available information take note of
corrections
Basic Diagnosis Upper GI bleeding
(Dx): secondary to NSAID
2 points gastropathy

Very good history. No Rewrite only the Rewrite the

need to part of the medical entire history & History (44)
rewrite. history & P.E with PE; re-submit _______
corrections and re- on _______ P.E. (50)
submit on together with _______
FINAL DISPOSITION:
_____________ the initial S.F. (03)
(Please check appropriate
together with the manuscript. _______
box)
initial manuscript. O.S.I. (03)
_______
Total (100):
____
FINAL GRADE:
%

Submitted by: MATIAS, Dan Angelo D. Date submitted: August 23, 2019

Facilitator: Date: August 23, 2019

Dan Angelo D. Matias

Signature over printed name

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