History and Physical Examination have been fundamental components of medical evaluation and diagnosis for centuries.
By gathering information about a patient’s medical history and conducting a comprehensive physical examination, healthcare providers can gain valuable insights into a patient’s health status, identify potential issues, and formulate appropriate treatment plans.
These processes provide a foundation for effective and personalized healthcare, enabling healthcare professionals to assess the overall well-being of individuals and make informed decisions regarding their care.
What Is H&P?
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The most formal and comprehensive evaluation of a patient and their condition is known as the History and Physical (H&P). H&P is a shortened term used to refer to the formal document doctors create after conducting an interview with the patient, performing a physical examination, and summarizing any obtained or pending test results.
The History section of the H&P includes a detailed timeline of the patient’s condition, commonly called the “chief complaint” or “CC.” In medical records, the chief complaint is often abbreviated as “CC” in the History documentation.
The Physical Exam evaluates the patient’s physical condition through objective and subjective assessments. The documentation of the Physical Exam is usually organized by body systems, such as HEENT (Head, Eyes, Ears, Nose, and Throat).
Objective measurements like blood pressure, pulse rate, and temperature are recorded. Additionally, subjective observations and palpation are performed, often requiring the healthcare provider to use their best judgment to assess factors like size, location, and involvement.
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Examples Of H&P
Here are examples of the sections that you could come across in a patient’s History and Physical (H&P) documentation.
History
Chief complaint
The chief complaint refers to the primary issue or the main reason a patient seeks medical attention.
Present illness
Present illness refers to a comprehensive account of the current symptoms, including detailed information about when they started, how long they have been present, their intensity, and accompanying factors or conditions.
Past medical history
Past medical history encompasses a person’s previous health conditions, surgical procedures, hospital stays, and noteworthy medical occurrences.
Medications
Medications entail a compilation of present medications, encompassing both prescribed and over-the-counter drugs and any vitamins or supplements being taken.
Allergies
Allergies refer to any recognized allergies or unfavourable reactions to medications or substances.
Social history
Social history involves gathering details about the patient’s way of life, including their occupation, habits related to tobacco or alcohol use, and any pertinent social factors.
Family history
Family history pertains to notable hereditary medical conditions within the patient’s family.
Physical Examination
Vital signs
Vital signs encompass the assessment of key physiological measurements such as blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation in the patient.
General Appearance
General appearance involves making observations regarding the overall physical appearance of the patient, including their level of distress, any noticeable abnormalities, and their overall demeanour.
Head and neck
Head and neck examination involves assessing the condition of the head, including the eyes, ears, nose, throat, lymph nodes, and neck.
Cardiovascular
Cardiovascular evaluation entails examining the heart, which involves listening to heart sounds, feeling the pulses, and assessing the peripheral circulation.
Respiratory
Respiratory assessment involves examining the lungs, which includes observing, feeling, tapping, and listening through a stethoscope (auscultation).
Abdomen
Abdominal assessment involves examining the abdomen, which includes visually inspecting, touching, tapping, and listening to bowel sounds using a stethoscope.
