history & physical (H&P)
Introduction
What brings you here... Anything else?
Attributes of a symptom:
- location, including radiation
- quality
- quantity or severity
- timing
- when did/does it start?
- how long has it last?
- how often does it occur?
- setting in which it occurs
- environmental factors
- personal activities
- emotional reactions
- other contributing circumstances
- exacerbating or alleviating factors
- associated manifestations
Past surgical history:
Medications:
- ask about dietary supplements as well as prescription drugs
Social history: lives *, occupation *, tobacco *, EtOH *, IVDA *
- General:
- fever/chills, night sweats, fatigue, malaise, weight change, sleep disturbance, anorexia, depression
- Infectious:
- Metabolic:
- Eyes:
- Ears:
- Nose:
- Throat:
- Neck:
- swelling, goiter, lymphadenopathy, stiffness
- Cardiopulmonary:
- Gastrointestinal:
- Urinary:
- dysuria, hematuria, nocturia, frequency, kidney stones, infections, urinary incontinence
- Genital (female):
- menstrual irregularity, vaginal discharge, dysparunia
- Genital (male): impotence, penile discharge, testicular pain
- Musculoskeletal:
- Skin:
- Neurologic:
- headaches, stroke, seizures, loss of consciousness, ataxia, tremors, gait disturbance, paresthesias, numbness
Vitals: Temp: *, HR: *, RR: *, BP: **/**
General:
HEENT: NC/AT, pupils, extraocular muscles, conjunctiva, sclera, oropharynx, dentition, tongue (CN12), gag, ears, hearing (Weber test & Rinne test), sinuses, masseter, temporal arteries
Neck: supple, adenopathy?, trachea, JVD, thyromegaly?
Back: spine, CVA tenderness
Lungs: percussion, expansion, auscultation (bronchophony, egophony)
CVS: RR, m/r/g (heart sounds), carotid bruits, PMI
Abdomen: BS, tenderness, distention?, hepatosplenomegaly?, pulse?
Extremities: edema, clubbing, cyanosis, fingers & nails
Skin: moist/dry, tenting?, lesions, erythema, tattoos
Pulses: radial, dorsalis pedis, posterior tibial, femoral
Lymphatics: axillary, inguinal
Alert, oriented X 3, MMSE if appropriate
CN II-XII (should have already been checked)
DTR: biceps: flexion at elbow (C5, C6) triceps: extension at elbow (C6, C7) brachioradialis: flexion & supination of forearm (C5, C6) patellar: extension at knee (L2, L3, L4) ankle: plantar flexion at ankle (S1)
check for clonus
check for tremor
- flexion at the elbow (C5, C6, biceps)
- extension at the elbow (C6, C7, C8, triceps)
- abduction at the shoulders (deltoids)
- shrugging of shoulders, turning of head (CN XI)
- extension at wrist (C6, C7, C8, radial nerve)
- handgrip (C7, C8, T1)
- finger abduction (C8, T1 & ulnar nerve)
- opposition of thumb (C8, T1 & median nerve)
- gait (if possible)
- rise from a sitting position without arm support
- heal to toe or tandem walk
- walk on toes: tests plantar flexion
- walk on heals: tests dorsiflexion
- if gait not testable:
- flexion at the hip (L2, L3, L4, iliopsoas)
- adduction at the hips (L2, L3, L4, adductors)
- abduction at the hips (L4, L5, S1, gluteus medius & gluteus minimus)
- extension at the hips (S1, gluteus maximus)
- extension at the knee (L2, L3, L4, quadriceps)
- flexion at the knee (L4, L5, S1, S2, hamstrings)
- dorsiflexion at the ankle (L4, L5)
- plantar flexion at the ankle (S1)
- finger to nose: tests for dysmetria (cerebellar)
- heel to shin, repeat with eyes closed to check position sense
- rapid alterating movements: tests for dysdiadochokinesis (cerebellar)
sensory: position sense, vibratory sensation
- Romberg
- pronator drift
- stereognosis
- 2 point discrimination: 5 mm on finger pads
Notes
- 85% of diagnoses may be correctly made from history & physical examination alone[1]
- routine testing beyond history & physical unnecessary[1]