Evaluation of Student H&P UNC Medicine Inpatient Clerkship
Student Name: ________________________________ Date Submitted: _______________
When Dr. Klipstein evaluates an H&P, he will consider the following issues:
History of
Present Illness
Includes a chief complaint
Appropriate dimensions of cardinal symptom are listed (including location, severity,
quality, setting, chronology, aggravating/alleviating, associated manifestations)
Chronological story begins at baseline state of health
Incorporates elements of PMH, FH, SH that are relevant to story (e.g. includes risk
factors for CAD for patient with chest pain)
ROS questions pertinent to chief complaint are included in HPI (not in ROS section)
HPI reflects knowledge of differential diagnosis
HPI narrative flows smoothly, in a logical fashion
Past Medical
History
Includes sufficient detail (onset, complications, and therapy) for key diagnoses (e.g.,
Type 2 DM, on pills since 1995, mild neuropathy, no known retinopathy/nephropathy)
Medications
Includes dose, route and frequency for each medication
Includes over the counter and herbal remedies
Allergies
Includes nature of adverse reaction
Review of
Systems
Most systems are evaluated (e.g. Constitutional, HEENT, Respiratory, Cardiovasc,
GI, GU, Neuro, Psych, Endocrine, Musculoskeletal, Hematologic/ Lymph, Skin)
Does not include PMH (ex. Cataracts or heart murmur belong in PMH, not ROS)
Does not repeat information already in HPI
Adequate depth (e.g. GI: no abdominal pain, bloating, nausea, vomiting,
melena, hematochezia, change in color, caliber, consistency or frequency of stool)
Social History
Occupation, marital status
Tobacco, EtOH, and substance abuse
Functional status, living situation
Family History
State of health of parents, siblings, children
Extended family occurrence of CAD, DM, HTN and cancer
Age at diagnosis of important diseases, especially if premature onset (e.g. CAD in
brother age 37, colon cancer in father age 42)
Physical
Examination
Includes areas relevant to the chief complaint (e.g. for patient with cirrhosis includes
presence/absence of stigmata of liver disease, for patient with CHF in differential
diagnosis includes presence/absence of JVD, crackles, murmur, gallops, liver size,
edema, etc)
Does not include assessments/interpretations in PE section (e.g. describes “8x10cm
oval area of warm, erythematous skin on medial aspect of left thigh” instead of
“cellulitis on medial aspect of left thigh”)
