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Rubric PDF

The document provides a guide for patient presentations, outlining the key components to include: 1) patient name, age, gender, 2) chief complaint and duration, 3) history of present illness including onset, location, duration, character, aggravating/relieving factors, timing, and severity, 4) review of systems, 5) past medical history, 6) past surgical history, 7) social history, 8) current medications, 9) allergies, and 10) physical exam findings. It also includes a rubric to ensure presentations cover patient identification, definition of medical terms, explanation of significance for findings and history, and connection of findings to underlying condition.

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Fauzan Zanne
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327 views2 pages

Rubric PDF

The document provides a guide for patient presentations, outlining the key components to include: 1) patient name, age, gender, 2) chief complaint and duration, 3) history of present illness including onset, location, duration, character, aggravating/relieving factors, timing, and severity, 4) review of systems, 5) past medical history, 6) past surgical history, 7) social history, 8) current medications, 9) allergies, and 10) physical exam findings. It also includes a rubric to ensure presentations cover patient identification, definition of medical terms, explanation of significance for findings and history, and connection of findings to underlying condition.

Uploaded by

Fauzan Zanne
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Guide to Patient Presentations

1. Name, age, and gender of patient


2. Chief Complaint: What is the patient here for, and how long has it been going
on?
3. History of Present Illness: details about the chief complaint (OLD CARTS)
• Onset—when did it start?
• Location/Radiation—where is it located?
• Duration—how long has this gone on?
• Character—does it change with any specific activities? Does the patient
use any descriptive words to describe the quality of the symptom?
• Aggravating factors – what makes it worse?
• Reliving factors – what makes it better?
• Timing—is it constant, cyclic, or does it come and go?
• Severity—how bothersome, disruptive, or painful is the problem?
4. Review of Systems: Anything else going on that may or may not be related to
the chief complaint.
5. Past Medical History: Major medical problems
6. Past Surgical History: Any surgeries the patient has had
7. Social History: sex, drugs, alcohol, job, stress levels, etc.
8. Medications: Current medications
9. Allergies: allergies and description of reaction
10. Physical Exam:
• Vital signs: BP, HR, RR, pulse ox, temperature
• General: Well developed, well nourished, no distress
• HENT: normocephalic, atraumatic, oropharynx clear, no ear/nose
discharge
• Eyes: anicteric, no discharge
• Neck: supple, no lymphadenopathy
• CV: regular rate and rhythm, no murmur or rub
• Lungs: clear to auscultation bilaterally, no wheezing
• Abdomen: soft, non-tender, non-distended, no mass or organomegaly
• External: no clubbing, cyanosis, or edema
• Neuro: alert and grossly nonfocal
• Affect: normal
• Skin: warm and dry, no rash
11. Labs: whatever was done
12. Imaging: CTs, Xrays, etc.
13. Pathology: if applicable which it always will be for our cases
Rubric for Clinical Case Presentations

Did the presenter…


❏ Identify the patient?
❏ Identify the chief complaint?
❏ Define any medical terms used in the HPI?
❏ Define any medical terms used in the review of systems?
❏ Connect any symptoms in the review of systems back to the
underlying disease or disorder?
❏ Define any medical terms used in the medical, surgical, and social
histories?
❏ Explain the significance of any provided past medical, surgical, or
social history?
❏ Connect any findings during the physical exam to the underlying
disease or disorder?
❏ Explain any tests performed on the patient?
❏ Define normal values for any laboratory or exam values given (such
as hematocrit, BP, HR)?
❏ Explain the significance of any laboratory results?
❏ Explain the significance of any imaging results?
❏ Explain and describe the provided pathology slides?

Bonus! Did the presenter…


❏ Provide additional pictures or videos to explain a symptom?
❏ Provide additional diagrams to explain a clinical question?

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