history & physical (H&P)

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Introduction

Chief complaint:

History of present illness:

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 medical history:

Past surgical history:

Allergies:

Medications:

Social history: lives *, occupation *, tobacco *, EtOH *, IVDA *

Family history:

Review of systems:

Physical examination:

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, distension?, 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

Neuro:

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)

Plantar flexion (Babinski)

check for clonus

check for tremor

motor:

sensory: position sense, vibratory sensation

Notes

  • 85% of diagnoses may be correctly made from history & physical examination alone[1]
  • routine testing beyond history & physical unnecessary[1]

More general terms

More specific terms

Additional terms

Components

References

  1. 1.0 1.1 1.2 Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2022