HISTORY AND PHYSICAL EXAMINATION (v6.0, MEK)

Patient Name:                                                Gender:            Age:            Race:

Location of Exam:                                Date of Exam:                 Date of Admission:

Chief Complaint (―What brought you into the hospital?‖—patient’s own words):

History of Present Illness
Be sure to include:
 quality
 for pain: location/radiation/severity
 chronology – onset, timing
  (intermittent, constant), duration,
  frequency, changes over time
 aggravating/alleviating factors
 associated symptoms
 pertinent risk factors
 effect on lifestyle/activities
 attributions (what does pt. think is
  causing the problem?)
 pt .reaction
 for write-up: include all important
  info relating to the problem,
  regardless of the ―section‖ of the
  medical database it comes from
 focus on pertinent positives &
  negatives for top 5 differentials

Past Medical History
Childhood Illnesses                           Current Medications                           Allergies (note specific reactions)
                                               dosages, OTC meds., alternative therapies

Additional Active Medical Problems:
Cancer, heart disease, diabetes,
hypertension, lung disease
   date of onset
                                                                                            Reproductive/Sexual History
   diagnosis/symptoms at onset
   relevant diagnostic tests (if known)                                                    sexually active (present/past)?
   complications / sequelae / progression                                                  sexual fn./dysfn.
   current management and status                                                           gender of sexual partners
                                                                                            contraception; STD prevention/hx.

                                              Habits / Risk Factors                         menarche (age)
                                               note attempts at behavior modification
                                              tobacco                                       menopause (age)
                                              alcohol                                       pregnancies (number)
                                              drugs                                         abortions: spontaneous       procedural
                                              caffeine                                      full-term       premature       living

                                              exercise                                      Health Maintenance
                                              diet                                          immunizations (current?)
Surgical History (incl. trauma & injuries)    travel /                                       testicular, mammograms, Pap smears,
 date, reason, complications, transfusions   exposures                                       breast exams, flexible sigmoidoscopy,
                                                                                              cholesterol, colonoscopy, PCP, dental
                                              HIV risk factors?                             preventive therapy
                                                                                             hormone replacement, aspirin, calcium
                                               IV drug use
                                               male homosexual activity                    devices
                                               blood transfusion prior to 1985              seat belts, smoke alarms, helmets
                                               sexual contact for drugs or money           gun safety

Family History
(―family tree‖ at right)
Ask about history of:
 cancer                thyroid disease                                                                                    Addiction:
 hypertension          arthritis                                                                                          Cut down
 hyperlipidemia        headaches                                                                                          attempts?
 heart disease         seizures                                                                                           Annoyed by
 diabetes              alcoholism/drugs                                                                                   others?
 illness similar to present illness                                                                                        Guilt?
 mental illness                                                                                                            Eye opener?
 stroke
 kidney disease

Social History
upbringing / education / military history                current life situation
                                                          living situation
                                                          relationships / social support
                                                          finances / insurance
occupations                                               stresses
                                                          satisfactions / interests
                                                         religion / spiritual support

cultural/ethnic background

Review of Systems
Sequence                                                            Comments/Notes
General: fevers; sweats; weight change; exercise tolerance;
―energy level‖; malaise, chills

Skin: rashes; pruritus; changing moles, lumps or lesions;
hair; nails

Head: headache; trauma
Eyes: vision; glasses; diplopia; inflammation; pain; redness
Ears: hearing; tinnitus; vertigo; pain
Nose: epistaxis; obstruction; sinusitis
Throat/Mouth: dental care; dentures; sores; sore throat;

Breasts: lumps; discharge; pain; swelling

Respiratory: dyspnea; pleuritic pain; cough; sputum
(description); wheezing; asthma; hemoptysis; cyanosis;
snoring; apnea; history of TB exposure; PPD; coughing
standing or lying down?

Vascular: chest pain; angina; dyspnea on exertion;
paroxysmal nocturnal dyspnea; orthopnea; peripheral edema;
history of murmur; palpitations; claudication; leg cramps;
history of DVT; hypertension; cold feet; lie on back?

Gastrointestinal: appetite; odynophagia; dysphagia;
heartburn; nausea; vomiting; hematemesis; jaundice;
abdominal pain; melena; hematochezia; diarrhea;
constipation; change in bowel habits; color of stool;
hemorrhoids; gas; bloating; gall bladder problem

Genitourinary: dysuria; nocturia; hematuria; frequency;
urgency; hesitancy; urinary incontinence; vaginal or urethral
discharge; sores; dyspareunia; testicular pain; swelling

Musculoskeletal: joint or back pain; swelling; stiffness;
deformity (list affected joints); muscle aches; locking of joints

Neurological: dizziness; involuntary tremor; blacking out;
loss of coordination; motor weakness or paralysis; memory
changes; speech; seizures; paresthesia

Psychiatric: depression; sadness; sleep disturbance; crying
spells; anorexia or hyperphagia; anhedonia;
suicidal/homicidal ideation; loss of libido; anxiety; eating
disorders (anorexia nervosa; bulimia; dissatisfaction with
body image); hallucination; delusions; behavioral changes

Hematologic: known anemia; easy bruising; heavy bleeding

Endocrine: polyuria; polydipsia; heat/cold intolerance

Functional Status (optional) – Activities of Daily Living
(ADLs): bathing; ambulating; toileting; transfer; eating;
dressing. Instrumental ADLs: shopping; cooking; mode of
transportation; telephone use; laundry; housekeeping;
responsibility for medicines/finances

Physical Examination
Sequence                                                                         Comments/Notes
Mental status exam (AAO X3)                                                      Awake, Alert, Oriented to Time, Self, and Place

Patient sitting, facing examiner
                                                                                 BP:              /              right arm, sitting
    Observe general appearance
    Examine hands & nails; examine skin throughout exam                         BP:              /              right arm       left arm            lying
                                                                                                                 sitting         standing
    Vital signs                                                                 BP:              /              right arm       left arm            lying
          measure blood pressure in right arm (in left arm and/or                                               sitting         standing
           sitting/standing/lying if indicated)
          compare radial pulses (15 sec.)                                       Temp                  Pulse                      Resp. rate
          count respiratory rate (30 sec.)
                                                                                 Weight                Height                     O2 saturation
    Eyes
           examine sclera and conjunctiva
           test visual acuity [check both eyes individually]                    Jaundice: both eyes               right eye                left eye
           test peripheral vision
           check extraocular movements (CN III, IV, VI), look for               Vision: both eyes                 right eye                left eye
            nystagmus [check both eyes individually]
           check pupillary light reflex (direct & consensual) [check both       CN III, IV, VI (extraoccular)
            eyes individually]
           check near reflex & accommodation
           perform fundoscopic exam – describe:
                 red reflex
                 cup-to-disc
                 vasculature
                 papilloedema!!!
                 macula

    Ears / Nose / Mouth
          pull helix/auricle, push tragus
          test hearing (CN VIII)                                                CN VIII (hearing): right ear                         left ear
          use otoscope to examine external canal and tympanic
           membrane, describing appearance and landmarks
          nasal patency
          inspect nose, septum, &turbinates using otoscope
          inspect mouth, buccal mucosa, teeth, gums, tongue, tonsillar          CN X (uvula, gag):
           fossa and pharynx
          have pt. phonate and inspect palate and uvula (CN X)                  CN XII (tongue):
          have pt. protrude tongue (CN XII)
          ask about gag refled (CN X)
                                                                                 CN V (massester, trigeminal):
    Head / Face
         observe and palpate head, face, hair, scalp, skull                     CN VII (eyebrows, smile, close eyelids):
         test for pain in sinuses (frontal & maxillary)
         have pt. bite down while palpating masseter muscles (CN V)
                                                                                 CN XI (shoulder shrug):
         test touch sensation in three regions of face (CN V)
         have pt. raise eyebrow, squeeze eyes shut and smile (CN VII)

    Neck / Thyroid
         have pt. shrug shoulders, and turn against resistance (CN XI)
         palpate lymph nodes in anterior and posterior cervical
          triangles, submandibular and supraclavicular areas (can be
          done in front of or behind pt.)

Examiner moves behind pt.

    Neck / Thyroid (cont’d)
         examine lymph nodes (if not done previously)
         examine thyroid gland

    Chest
         inspect chest, observing breathing pattern
         test for symmetrical breathing
         palpate vertebral column
         palpate costovertebral angles with edge of hand (karate chop)

          percuss posterior & lateral lung fields using bimanual
          auscultate posterior & lateral lung fields, comparing both
           sides [ask pt. to breath through mouth]

Examiner moves in front of pt.

    Chest (cont’d)
         auscultate anterior lung fields
         inspect anterior chest wall

    Breasts / Axillae
         observe breasts for symmetry, skin abnormalities, retraction
         observe breasts with hands on hips, and over head

Patient at 45°, examiner on patient’s right side

    Breasts / Axillae
         using double drape technique, inspect and palpate 4 quadrants
          (including axillary tail)
         examine and palpate nipple
         palpate axillary lymph nodes

    Heart / Vessels
         palpate carotid artery
         auscultate the carotids for bruits
         examine JVP
         palpate for PMI and for parasternal heaves & palpable thrills
         auscultate the precordium, listening for normal and abnormal
          heart sounds and murmurs

    Abdomen / Inguinal areas
        using double drape technique, inspect the abdomen, look for          Strength (5 pt.):RIGHT LEFT
         guarding                                                             grip
        auscultate the abdomen for bowel sounds and abdominal                finger abduction                 0 = no contraction
         bruits                                                               wrist flexion                    1 = slight contraction, no joint motion
        percuss in 4 quadrants                                               wrist extension                  2 = complete ROM w/o gravity
        palpate all 4 quadrants, superficially and deeply                    elbow flexion                    3 = complete ROM w/ gravity
        palpate for liver and spleen                                         elbow extension                  4 = complete ROM w/ gravity & some
        percuss liver & measure span                                         shoulder abd.
                                                                              shoulder add.                    5 = complete ROM w/ gravity & full
        palpate inguinal areas for lymph nodes
                                                                              arms over head                   resistance
        palpate femoral pulses and auscultate for bruits

Patient sits, facing examiner                                                 Strength (5 pt.):RIGHT   LEFT
                                                                              ankle flexion
    Musculoskeletal + neurological                                           ankle extension
                                                                              knee flexion
        inspect upper extremities
                                                                              knee extension
        test upper extremity motor strength & joint mobility (ROM):
                                                                              hip flexion
         grip, finger abduction, wrist flexion/extension, elbow
                                                                              hip extension
         flexion/extension, shoulder abduction/adduction (scarcrow),
         arms over head
                                                                              DTR (5 pt.)
        test pronator drift
                                                                                  RIGHT                LEFT
        inspect lower extremities                                                                             0 = no response
        test lower extremity motor strength & joint mobility (ROM):              triceps_____         _____   1 = hyporeflexia
         ankle flexion/extension, knee flexion/extension, hip flexion/            biceps_____          _____   2 = normal
         extension                                                            brachiorad _____         _____   3 = hyperreflexia w/o clonus
        palpate for edema                                                      asterixis_____         _____   4 = hyperreflexia w/ transient clonus
        palpate dorsalis pedis and posterior tibialis pulses                                                  5 = hyperreflexia w/ sustained clonus
        check touch/vibration sensation in arms & legs                          patellar_____         _____
        heal-to-shin                                                            achilles_____         _____
        test reflexes: biceps, triceps, brachioradialis, knee, ankle
        Babinski’s sign                                                      Sensation (5 pt.): RIGHT LEFT
Patient stands                                                                Light tough
                                                                              Position sense
    Musculoskeletal + neurological (cont’d)
        if mydriatic solution was used, perform fundoscopic exam             Cerebellar (5 pt.): RIGHT    LEFT
        deep knee bend                                                       Finger-to-nose
        test gait, observing balance and arm swing                           Heel-to-shin

        Romberg                                                      Romberg

   Male Genitalia
        exam penis, testes, epididymis
        check for inguinal hernias
   Rectal exam
        examine anal orifice
        perform digital exam, noting muscle tone and examining
         prostate and rectal vault for masses


To top