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history & physical (H&P)
Chief complaint:
History of present illness:
What brings you here... Anything else?
Attributes of a symptom:
1) location, including radiation
2) quality
3) quantity or severity
4) timing
a) when did/does it start?
b) how long has it last?
c) how often does it occur?
5) setting in which it occurs
a) environmental factors
b) personal activities
c) emotional reactions
d) other contributing circumstances
6) exacerbating or alleviating factors
7) associated manifestations
Past medical history:
Past surgical history:
Allergies:
Medications:
- ask about dietary supplements as well as prescription drugs
Social history: lives *, occupation *, tobacco *, EtOH *, IVDA *
Family history:
Review of systems:
- General:
- fever/chills, night sweats, fatigue, malaise, weight change, sleep disturbance, anorexia, depression
- Infectious:
- Tuberculosis, AIDS, sexually-transmitted diseases
- Metabolic:
- diabetes, thyroid disease
- Eyes:
- blurring of vision, visual field loss, irritation
- Ears:
- deafness, tinnitus, vertigo, earache
- Nose:
- rhinitis, sinusitis, epistaxis
- Throat:
- sore throat, tonsillitis, hoarseness
- Neck:
- swelling, goiter, lymphadenopathy, stiffness
- Cardiopulmonary:
- heart disease, myocardial infarction, congestive heart failure, chest pain, palpitations, edema, hypertension, dyspnea, PND, cough, hemoptysis
- Gastrointestinal:
- nausea/vomiting, diarrhea, constipation, hematemesis, BRBPR, melena, peptic ulcer disease, GERD, dysphagia, bloating pain
- 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:
- myalgia, arthralgia, arthritis
- Skin:
- rash, pruritus, bruising, open sores
- Neurologic:
- headaches, stroke, seizures, loss of consciousness, ataxia, tremors, gait disturbance, paresthesias, numbness
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:
- 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]
Related
physician evaluation at nursing home admission
Specific
admission history & physical
physical examination
General
clinical procedure
References
- Medical Knowledge Self Assessment Program (MKSAP) 17, 19
American College of Physicians, Philadelphia 2015, 2022
Components
physical examination