How to: History and Physical Exam Daily Hospital Follow

After the first day of admitting a patient into the hospital, you will be expected to
see your patient each morning before work rounds with your team. This visit is
much more focused.

Planning: BEFORE you enter the room

1) Review the chart for updates on morning arrival (vitals, lab testing, consults or other notes
written)
2) Check in with nursing regarding any overnight updates – (ie how was the patient’s confusion
overnight)
3) Budget about 15 minutes of time to be in the room with the patient

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Interview:

1) Introduction: Greet the patient by name (check their arm band), re-introduce
yourself, clarify your role and the purpose of the current encounter

2) Start with open ended questions:

How are you feeling this morning?
Is there anything new going on or bothering you?

3) Focus on questions regarding their presenting illness (ex: If they are admitted with a heart
attack: Any chest pain, palpitations, sob, dizziness, etc?) Explore if they’re doing
better/same/worse.

4) Consider gathering information about how they are doing during their hospital stay:
Have they been ambulating?
Any trouble with medications?

Physical Exam:
1. Wash your hands (before and after)

2. Be mindful of the patient’s comfort and modesty (i.e. asking family members to
step out, closing the curtain/door, draping)

3. The exam should be performed in an organized and logical manner from head to
toe minimizing patient movement and undressing

4. Always listen to the heart and lungs, examine the abdomen and check lower
extremities for edema

5. Pay specific attention to the pertinent areas of concern. What should you
examine to see if the patient is getting better?