You are on page 1of 6

History and Physical Template

CC: A succinct description of the symptom(s) or situation responsible for the patient's presentation for health
care. It is often helpful to use the patient's own words recorded in quotation marks.
HPI: This is the key part of the recorded history. The HPI is sometimes begun with a short list of the patient's
major medical illnesses so that the reader or listener has a frame of reference in which to understand the
present illness (e.g. Mr. M. is a 55 y/o man with diabetes, hyperlipidemia and hypertension who came to
the Emergency Department with.). Begin with the patient's departure from their usual state of health
and present an orderly, chronological, narrative account of symptoms, and events pertinent to the
current illness. The timing of symptoms and events should be documented with an interval (e.g. Pain
started three days ago.) or calendar date rather than day of the week. Details of medical care received
during the present illness should be given. If the patient or informant does not know the answer to any
important question, include this fact (e.g. Patient does not know the liver biopsy results.).
Characterize all symptoms in the HPI as follows:
1) Chronology. When did it start?
2) Location. Where is it? Does it radiate?
3) Quality. What is it like?
4) Intensity. How bad is it?
5) Duration. How long does it last?
6) Frequency. How often does it come?
7) Setting in which it started and/or occurs?
8) Exacerbating factors?
9) Alleviating factors?
10) Associated symptoms?
11) Past experience with symptoms?
Information obtained in the Review of Systems which is pertinent to the evaluation of the current illness
should be included in the HPI. Include a statement regarding symptoms or events that are expected with
a particular illness, but which were not present. These are known as "pertinent negatives. As students
advance in their knowledge of disease, the pertinence of historical features, whether present or absent,
becomes more evident. Information presented in the HPI should not be repeated in subsequent sections
(e.g. cardiac symptoms mentioned in the HPI should not be repeated in the ROS).

PMH:
Significant Illnesses: Include all significant current medical conditions not included in the HPI. Give
details. List in order of importance and note date of onset/diagnosis. Pertinent details of each
condition should be recorded chronologically. Include behavioral health/psychiatric problems. Also
include any major health problems patient had as a child.
Surgical History: List any surgical procedures the patient has had, including date.
Reproductive History: For adult female patients only; pregnancies with dates, complications and
outcome. Age at onset of menses or menopause. Birth control measures.
Hospitalizations: List any hospitalizations the patient has had, including date and reason for admission,
and any major events/complications occurring during those hospital stays.

Health Maintenance: Comment on the following aspects of health care:


Functional Status: Comment on patients independence in Activities of Daily Living (ADLs):
mobility in home, toileting, bathing, eating, dressing most relevant for elderly and disabled
patients.
Health screenings: Comment on patients status of applicable health screenings (according to age
and sex), including when they last occurred (for women: PAP smear/pelvic exam;
mammography; for men: rectal/prostate exam); dental care
Immunizations: Comment on patients immunization status, i.e., whether or not they are up to date
on the routinely recommended vaccinations for their age group. If reported verbally only
(without documentation), state per patient report. If unknown, say so.
Diet: Comment on any dietary restrictions, food intolerance, dietary fads, use of caffeinated
beverages.
Exercise: What activities? How often? Duration?

MEDICATIONS: Include prescription drugs, over the counter preparations, herbal/home remedies. List
names, dosage, frequency and duration of usage.
ALLERGIES & ADVERSE DRUG REACTIONS: Known allergies and/or adverse reactions to medicines
(prescription or "over the counter"). Describe allergic or adverse reactions.
FAMILY HISTORY: Separately list all 1st degree relatives. Record relation to patient, age (now or at time of
death) and health status (living, well, sick, dead). If dead, what was the cause? "Are any illnesses common in
your family?" A diagram of a family tree should be drawn if the disease seems familial.

PSYCHOSOCIAL HISTORY:
Marital Status:
Living arrangements: who patient lives with.
Occupation (incl. any unusual environmental exposures: Exposure to toxins (silica, asbestos, etc.)
Sexual History: Are you sexually active? If yes, Any problems and Do you have sex with women,
men or both?
Tobacco use (type and quantify): Differentiate ex-smoker from never smoker. Calculate "pack years." Quit
attempts. Desire to quit.
Alcohol and drug use (type and quantify): Include marijuana, heroin, cocaine, barbiturates and other illicit
psychotropic agents. Route of use: oral, smoke, injection. How much. How often.

REVIEW OF SYSTEMS: Often called the Review of Symptoms to emphasize the focus on the patients
current or recent symptoms rather than diagnoses (covered in the PMH). Be selective in reviewing the
patients organ systems according to their relevance to your differential diagnosis for the patients chief
complaintyou need not review every single system type for every patient. In addition to asking specific
questions, also be sure to assess for any other symptoms as a general statement, to ensure youre not
missing anything. See appendix for example questions for each system.

PHYSICAL EXAM: This should always include a set of vital signs and assessment of general appearance,
in addition to any other PE maneuvers you perform/assess; you should list here a description of all
normal findings and all abnormal findings you encounter on examnot just positive/abnormal ones,
and in doing so, include a description of your findingsnot simply normal or abnormal, as these
terms are not very descriptive or helpful to your reader. You need not assess every organ systemonly the
ones that are relevant to your differential diagnosis for a patient, in addition to any screening exam
maneuvers you perform to ensure you dont miss any major findings you didnt expect.
VS: list vitals, including weight, if you have one recorded.
Gen: comment on general appearance, including patients severity of illness (well-appearing vs. illappearing or toxic appearingthe latter should be reserved for patients who appear to have a lifethreatening condition)
HEENT: list here any of the following assessed as part of your HEENT exam: head shape, scalp
appearance (deformities, injuries, bruises, etc.), eye exam (inspection; may include CN assessment or
Fundoscopic exam findings here, but these findings alternatively can be listed in Neuro exam section);
ear exam; nasal cavity exam; sinus exam; oropharynx exam
Neck: list here any of the following assessed as part of your neck exam: cervical lymph node exam; thyroid
exam; neck range of motion; neck masses.
CV: list here any of the following assessed as part of your CV exam: great vessel exam (JVP, carotids),
cardiac auscultation, PMI assessment, pulse strength assessment, capillary refill time
Resp: list here any of the following assessed as part of your respiratory exam: lung auscultation, presence
of any findings of labored breathing (and specify which onese.g., retractions, accessory muscle use,
grunting, etc.).
Abd: list here any of the following assessed as part of your abdominal exam: inspection, palpation,
percussion, auscultation; specifics of liver exam (tenderness, size/span, contour); presence of any
masses, tenderness to palpation (how severe, and location of; if TTP present, comment on presence or
absence of rebound tenderness or guarding), abdominal distension.
GU: list here any maneuvers assessed as part of your GU exam, if conducted.
Extr: list here any of the following assessed as part of your extremities exam: warmth to touch; pulse
strength, cap refill time (if not mentioned in CV); presence of cyanosis or edema; if edema present, state
whether it is pitting or nonpitting, and how severe; note any skin changes in extremities here or in Skin
section.
Neuro: list here any maneuvers assessed as part of your neuro exam.
Skin: list here any findings assessed as part of your skin exam: presence of any rashes, unusual lesions,
petechiae, purpura, ecchymoses (bruises), including location of any of these findings.
Psych: list here any findings assessed as part of your mental health assessment.

ASSESSMENT: The Assessment portion of the written case presentation has 2 components: a summary
statement (the problem representation) and a differential diagnosis for what you think is causing the
patients clinical findingsincluding both their chief complaint and any abnormalities detected on historytaking and physical examination.
Start the assessment section with the summary statement of the patients demographic features, major
clinical findings, and any relevant risk factors (e.g., The patient is a 2 month-old term, previously healthy
male infant who presents with URI symptoms, fever, signs of acute respiratory distress, and bilateral diffuse
crackles on lung exam.). The summary statement includes the patients age, any other significant
epidemiologic factors such as race, aspects of the social history that might influence the differential
diagnosis (e.g. retired coal miner for a patient with respiratory difficulties), chief complaint and the most
important abnormalities that you found. If the patient has a chronic illness such as diabetes that might be
contributing to the presenting problem, you can include it in the summary sentence.
After your summary statement, list your differential diagnosis: (e.g., The patient is a 2 month-old term,
previously healthy male infant who presents with URI symptoms, fever, signs of acute respiratory distress,
and bilateral diffuse crackles on lung exam. These findings are concerning for the following possible
etiologies:..). Your differential diagnosis should be both complete (representing the breadth of possible
diagnoses consistent with the patients presentation; at minimum, this should include common diagnoses
and life-threatening possibilities) and justifiedthis means you need to list the clinical findings from the
H&P that support the diagnoses on your differential; findings that argue against alternative diagnoses
should also be discussed.
Include all of the following information when discussing your justification for including the diagnoses on
your differential:
o Pertinent positives from the history and physical exam that support (are consistent with) each
diagnosis. For your leading/working diagnosis, this includes stating clearly and explicitly why this
particular diagnosis is top on your differential, based on the information you have.
Recognize any pertinent findings from the case that do not fit a diagnosis on your list, if there
are any, and state why they dont fit.
o Pertinent negatives from the history and physical exam that argue in favor of the diagnoses on your
list and against other alternative diagnoses that could present in the same way as the diagnoses on
your list
This is particularly important for any life-threatening conditions that could also cause the
clinical features seen in your patient, because you need to be able to defend why youre
reassured that your patient is highly unlikely to have those other conditions (if you are, in fact,
confident that the likelihood your patient has a particular life-threatening condition is low).
o A brief explanation of the pathophysiology of your leading diagnosis that helps to explain how the
mechanism from this disease could cause the clinical findings seen in your patient
Details about the specific molecular biological mechanisms are generally not necessary, if you
can summarize the general concept in fewer wordsone or 2 sentences should suffice, in most
cases.

PLAN: Your plan should include all of the following; you may organize this by problem or by organ system:
o Diagnostic work-up you recommend to determine the etiology of the patients presenting
complaint/major findings; you need to include justification for any labs or studies you recommend,
including which conditions on your differential diagnosis youre looking for with each study.
o Anticipatory guidance to the patient: what to do/not to do, while youre figuring out whats wrong.
o Management/treatment recommendations for what you think is most likely occurring include
justification, referencing your differential and your level of concern for the patients most likely
condition.
o Disposition of the patient: will you send them home with follow-up appointment with you? Send to ED
for evaluation? Send to hospital for inpatient admission? etc. justify your disposition as well, based
on your level of concern for the patients most likely condition.

APPENDIX:
Example questions for Review of Systems (ROS)

General: A general statement regarding state of health (include emotional) & sense of well-being. Weight
change, fever or chills, diaphoresis; fatigue or change in energy level
Skin: Color changes, pruritus, eruptions, petechiae, moles, birthmarks, hair distribution and character, hair loss,
changes in nails.
Hematopoietic and Lymphatics: Known anemia, easy bruisability, spontaneous or excessive bleeding.
Enlarged or tender lymph nodes.
Head: Headaches, trauma.
Eyes: Use of corrective lenses, vision including recent changes, date of last refraction and glaucoma screening,
pain, inflammation, scotomata, floaters, photophobia, periorbital swelling.
Ears: Hearing, tinnitus, pain, discharge, vertigo.
Nose and Sinuses: Epistaxis, nasal discharge, obstruction, postnasal drainage, facial pain.
Mouth: Lesions on lips or buccal mucosa, gingival bleeding, dental repair, sore tongue, sore throat, hoarseness.
Breasts: Lumps, nipple discharge, pain.
Respiratory: Shortness of breath, chest pain, pleurisy, cough, sputum (appearance and amount), hemoptysis,
wheezing, dyspnea.
Cardiovascular: Chest pain or pressure, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea,
palpitations, syncope, varicosities, stasis ulcers, claudication.
Gastrointestinal: Appetite, nausea, vomiting, hematemesis, food intolerance, belching, indigestion, heartburn,
use of antacids, dysphagia, abdominal pain, change in abdominal girth, jaundice, flatulence, diarrhea,
constipation, change in bowel habits, melena, hematochezia.
Urinary: Changes in urine color, change in frequency, increased or decreased volume, urgency, hesitancy,
straining, passage of stones, incontinence, change in size and force of stream, dribbling, dysuria, flank or
suprapubic pain, gross hematuria.
Male Genital: Inguinal discomfort, known hernias. Erectile dysfunction. Testicular pain, tenderness, lumps.
Penile lesions, urethral discharge. Sexual development, if relevant.
Female Genital: Usual frequency, regularity and duration of menses, date of last menstrual period, abnormal
uterine bleeding, vaginal discharge, vulvar pruritus, painful intercourse/dyspareunia., menopausal symptoms
Neuromuscular: Paralysis or weakness, loss of sensations, paresthesias, convulsions, loss of normal balance or
coordination, syncope, tremor, muscle pain or atrophy.
Skeletal: Pain in extremities or spine, stiffness and duration/timing of stiffness, limitation of motion, joint
pain/inflammation, fractures or joint injuries, bone pain.
Endocrine: Hair distribution, heat or cold intolerance, goiter, polyphagia, polydipsia, polyuria.
Psychological: Anxiety, depression (If yes, any thoughts of suicide of self injury), changes in sleep or appetite,
memory difficulties.