UST FACULTY OF MEDICINE & SURGERY

Department of Medicine

Medicine II
Data Base-Case Discussion_ version August 2016

Name of Student (Initials only) ___________________ Subsection ____

____________

Date

Med II Block:
( ) # 1. Cardiology_Pulmonology_Nephrology_Endocrinology FACILITATOR:
________________________
( ) # 2. GI_Infectious_Hematology_Oncology_Rheumatology FACILITATOR:
________________________

1ST Revision

Original manuscript

2nd Revision

HISTORY TAKING
(25 points)

1. General Data/Information:

(Should contain ALL information listed below)

Name (initials only):

Age:
Gender:
Birthday/Birthplace:
Nationality/Citizenship:
Educational attainment:
Civil Status:
Occupation:
Home Address:
Provincial address:
Contact number:
Informant/s (relationship to patient/Reliability):
Date admitted in USTH:
Date of Interview:

Religion:

2. Chief Complaint/s: (State briefly actual language used e.g. Tagalog; and the correct English translation consistent with or in context with the HPI)
3. History of Present Illness (HPI): Write in chronological order; Describe symptoms according to onset, location, duration, character,
aggravating or associated factors, relieving factors, temporal factors and severity; Note the pertinent negatives;

4. Review of Systems:

(Review and list ALL symptoms pertinent to the working diagnosis but were not accounted for in the HPI. Do not repeat any data

already mentioned in the HPI)

5. Past History:

(Record previous childhood and adult medical and surgical illnesses and hospitalizations; injuries/ accidents; obstetric/ gynecologic history
i.e. family planning method used
6. Current Health Status/Risk Factors (Record health screening, nutrition/dietary habits, sleep pattern, exercise, smoking, alcohol,
environmental exposures, medication data, immunizations)

7. Family History:

(List the common genetic disorders and major health conditions in the patients family - identify specific family members; include Medical
Genogram or Family Diagram i.e. 3 - 4 generations)

8. Personal/Social History: (Describe the cultural background, family structure & relationships, marital status, stress factors, educational data,
economic status; environmental data; occupational/ employment history; sexual history); Elaborate on the social history (*see NEJM Oct 2, 2014 issue)

EVALUATION
OF HISTORY
TAKING
25 points

II. PHYSICAL
EXAMINATION
(25 points)

1. General Survey:
2. Vital Signs:

25 --- 20

19 -- 15

14 --- 10 ------------------- 0

Able to identify and discriminate

important historical information. Made
an organized, thorough, and complete
history.

Described important clinical data

pertaining to chief complaint
although incomplete. Noted
some discordant clinical
information.

Incomplete history; Recorded

history but unable to obtain
important clinical data relating
to chief complaint/Organsystem

__ No need to
Rewrite history
__ Rewrite & take
note of corrections

__________ Date of Admission (Current hospital confinement at USTH-CD)

__________ Date this physical exam was performed by the medical student
(Make a complete and accurate general survey; Describe findings adequately)

(Record current vital signs including anthropometric data eg. BMI)

3. Skin: (Describe findings adequately and include images of lesions -obtain patients consent; State pertinent negatives)

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ivillespin/lanzona 8-20-15

UST FACULTY OF MEDICINE & SURGERY

Department of Medicine

Medicine II
Data Base-Case Discussion_ version August 2016

4. HEENT/Neck:

(Describe and illustrate findings adequately; include thyroid and fundoscopic findings)

5. Thorax/Breast/Lungs:

*Lung Auscultogram:

(Describe and illustrate findings adequately. Report pertinent negatives).

(Illustrate the patients I P P A lung findings using NVB auscultogram)

6. Cardiovascular: (Describe findings adequately. Observe correct sequence i.e. I - P - A. State pertinent negatives).
*Heart Auscultogram:

7. Gastrointestinal:

(Draw your cardiovascular findings i.e. heart sounds, murmur - including the JVP, CAP and peripheral pulses)

(Describe findings adequately; Note correct sequence of abdominal exam ie. I-A-P-P; Include rectal if necessary; State pertinent

negatives)

8. Genito-urinary:

(Describe findings adequately; Include rectal if necessary; State pertinent negatives)

8. Musculoskeletal: (Describe findings adequately; Include MMT if necessary; State pertinent negatives)
9. Extremities: (Describe findings adequately; State pertinent negatives)
10. Neurological: (Describe findings adequately; Note correct sequence of examination. State pertinent negatives)
EVALUATION
OF PHYSICAL
EXAM
25 points

III.
Page | 2

25 --- 20
Performed a complete and focused
PE.

19 -- 15
Lacks some important/relevant
PE findings.

14 --- 10 ------------------ 0
Performed an incomplete &
focused PE. Did not perform
some important / relevant PE
exam on the organ-system
involved.

__ No need to
Rewrite PE
__ Rewrite & take
note of corrections

CASE DISCUSSION (Problem-Based)

ivillespin/lanzona 8-20-15

UST FACULTY OF MEDICINE & SURGERY

Department of Medicine

Medicine II
Data Base-Case Discussion_ version August 2016

(Total = 50 points)

A. PROBLEM
LIST
(5 points)

Note: Please use the Master Problem List (MPL) sheet. Read carefully the
DEFINITION OF A PROBLEM at the bottom of the MPL table.
Problem #1
Problem#2
Problem#3
54
Organized, thorough, and complete
MPL. Understood and applied correctly
the concepts used when stating a
PROBLEM as defined here. Higher
order thinking skills were evident
(Blooms)

B. DISCUSSION

32
Incomplete, disorganized and
too compartmentalized.
Problems included were based
only on hearsay. Applied lower
order thinking skills

1 0
MPL is grossly lacking;
Critical thinking/ clinical
reasoning was lacking.

__ No need to
rewrite
__ Rewrite & take
note of corrections

General Instruction: Discuss each problem in the MPL using the S-O-A-P
format, where:
S = Subjective findings/ Symptomatology i.e. a BRIEF historical narrative
pertinent/germane to the problem statement (Patient perspective)
O = Objective or physical examination findings (Doctor perspective)
A = Assessment or analysis of the S & O data; TO ENUMERATE at least 3
differentials and BRIEFLY explain your basis; to discuss its relationship (i.e.
association or correlation) with other problems in the MPL; to state the
disease prognosis using the most current literature
P = Plan of action for each problem in the MPL which includes: a) Diagnostic
b) Therapeutic c) Education/ Prevention

1. Diagnostics:
Diagnosis &
Differentials

2. Management:
Diagnostic Plan
(D) Treatment
Plan (T)
Education (E) &
Preventive
Measures
45 points:
(15 points per problem)

Instruction: Discuss separately the S O A for each problem (Note:

Signs & symptoms may be repeated or rewritten in all enumerated problems
only if deemed relevant and contributory)
Problem #1:
SOAP- (D/T/E)
Problem#2:
SOAP- (D/T/E)
Problem#3:
SOAP- (D/T/E)
(Note: If more than 3 problems are being considered, PRIORITIZE your list (MPL)
according to the order of importance, severity and/or chronology of the problems
identified. ALWAYS BE CONSISTENT WHEN WRITING YOUR PROBLEM STATEMENTS IN
YOUR MPL AND DISCUSSION

Rubrics for Diagnostics (S- O- A-)

8 76

Page | 3

5 4 3

2 10
ivillespin/lanzona 8-20-15

UST FACULTY OF MEDICINE & SURGERY

Department of Medicine

Medicine II
Data Base-Case Discussion_ version August 2016
Complete, organized, brief, and
included only the relevant
SUBJECTIVE & OBJECTIVE data that
are deemed contributory to EACH
problem and subsequently able to
make a correct, logical and complete
assessment including the prognosis.
Able to enumerate the differential
diagnosis (from the MOST to the
LEAST LIKELY) with brief discussion.

Lacking or included subjective

and/or objective data that are
irrelevant or noncontributory to
the problem. Explanation of S & O
data lack basis or logic;
Incomplete list of differentials;
Included diseases that logically
should not be considered;

Majority of the S & O data

included are irrelevant to
the problem. Unable to
make a logical
assessment/diagnosis
based on the S & O.
Minimal explanation done;
Lacking differentials

__ No need to
rewrite
__ Rewrite & take
note of corrections

Rubrics for Management Plans (P- )

C. Final
Disposition

7 65
Able to formulate an appropriate and
rational diagnostic & treatment
strategies focusing on plans that will:
a). Need utmost priority and should be
immediately done b). Confirm and
support the problem or address lifethreatening situations c). Provide the
evidence to rule out differentials
mentioned d). Address costcontainment schemes bearing in mind
financial resources of the patient.
Incorporated recent or up-to-date
guidelines and briefly cited relevant
journals in the discussion.

43
Able to formulate a satisfactory
diagnostic & treatment strategy
but is incomplete. Enumerated
plans included a) those that may
be delayed b) were requested
only for baseline purposes c) may
add financial burden to the
patient.

21 0
Diagnostic and treatment
strategies are incomplete
and minimal. Enumerated
plans included a) nonpriority or just alternatives to
support the problem b) offer
little benefit to the patient, or
c) costly procedures that will
cause unnecessary harm.
No guidelines or journals
cited.

Very good/ Satisfactory clinical

history and case discussion. No need
to rewrite.

Rewrite only that part of the

clinical history or Case Discussion
with correction and re-submit on
(Date) ________ together with the
initial manuscript.

Rewrite the entire

History & PE; and re-submit
on (Date) ____________
together with the initial
manuscript.

*This portion to be
filled up by your
facilitator

__ No need to
rewrite
__ Rewrite & take
note of corrections

SCORE:
I. History :
II. Physical

Exam:
III. Case

Discussion:

Total: _______

Submitted by / Signature over printed name / Date:

_____________________________________________________________
_____________
Students name:
(Last)
(First)
(Middle)
Date

Facilitator: ______________________________________
_____________

Date Received/Checked:

Signature over Printed Name

Page | 4

ivillespin/lanzona 8-20-15

UNIVERSITY OF SANTO TOMAS HOSPITAL

Espaa Blvd., Manila 1015
Tel Nos. 731-3001 to 29; http://www.usthospital.com.ph
DEPARTMENT OF MEDICAL EDUCATION AND RESEARCH

*NOTE: This form is for practice use only by medical students and is not an official hospital
document
Patie
nt
Nam
e
Date of

Last Name:
First Name:
Middle Name:
Admission:

Age:

Gender:
Male
Female

Ward:

Room/Bed No.

Hospital No.

Out Patient Services

Emergency Room
Date of 1st consultation at OPS
Private Division
______________________
Clinical Division
Chief Complaint/s or Chief Concern (Tagalog word or phrase/ English translation):
Date of MPL:
Problem
Number
(Permanentl
y assigned
no.; either
retain or
retire no.
when
revising
MPL)

PROBLEM LIST
(List your Problem Statements according
to the order of importance, severity
and/or chronology)

Page | 6

MPL Revision Number:

Date problem
Action Taken
when upgrading this
was
initial problem to a
noted/recogni
higher level of
zed
(Date of
appearance or
diagnosis of
problem; Date of
intervention)

understanding
a.
Example: see problem
#

Date

proble
m was
resolve
d

To a
higher
level OR
b. Date
cured

ivillespin 8-19-15

UNIVERSITY OF SANTO TOMAS HOSPITAL

Espaa Blvd., Manila 1015
Tel Nos. 731-3001 to 29; http://www.usthospital.com.ph
DEPARTMENT OF MEDICAL EDUCATION AND RESEARCH
NOTE: Please red this carefully before constructing your MPL. You may use the backpage
for additional MPL space.
WHAT IS A PROBLEM?
a. It may be a symptom, a group of symptoms, an abnormal PE finding, laboratory or imaging
results, a previously confirmed diagnosis, a pathology report, a treatment or surgical procedure
b. Any condition needing further diagnostic and/or treatment intervention and follow-up
medical/surgical care.
c. ALL problem statements must be supported by hard data.
d. No hearsay evidence is allowed.
e. AVOID writing in the Problem List column the following words/phrases: Possible or probably
due to; to consider (T/c); rule in (R/i); rule out (R/o); Secondary to; Versus (vs) and question
mark (?)
f. Your differential diagnoses should be written in the assessment portion of the progress notes NOT in the MPL form.
Prepared by:
3rd Year Medical
Student
Junior Intern/ PGI/
Resident
Validated by:
Attending
Physician/
Consultant/
Medicine II
Facilitator
Disposition:

Page | 6

______________________________________
Signature over Printed Name

Date:

______________________________________
Signature over Printed Name

Date:

______________________________________
Signature over Printed Name

Revise this MPL

Date:
No need to

revise

ivillespin 8-19-15