What is an “H&P”

• H = history A comprehensive problem-focused AND patient specific history

• P = physical  A comprehensive screening physical exam
• Depending on the setting, includes breast and GU exam (not when they are just getting admitted to the hosp unless the complaint is
“breast mass” or something related)

When DO YOU perform an “H&P”?

 When a patient is brand new to you
 When a patient is admitted to the hospital
 When you see a patient as a specialty consultation (e.g. Cardiology)
 When the initial workup was inconclusive
 When a patient needs a health maintenance/screening exam  Patients call this a “yearly physical”
Purpose?
Comprehensive health history
Childhood history, OB history (if female), Psychiatric history, Extended family history, Detailed social history, Health maintenance: immunizations and
age-appropriate screening, Full review of systems
Establish a baseline of historical data and current physical exam findings
For hospital admission – gives a picture of patient’s condition at the time of admission
Comprehensive health screening exam

Comprehensive Medical history

Detailed medical history – creates a timeline Obstetric history – Gravida# Para# Detailed surgical history
 When diagnosed/currently controlled  G – total number of pregnancies  When/why
 Previously therapies tested  P – how many babies birthed  Complications
 Diagnostic procedures  T – term, P – preterm, A – abortions, L – living children Childhood history
 Specialists  What kind of deliveries?  Illnesses
 e.g. Vaginal, cesarean section, assisted w/ – forceps, suction  Hospitalizations, Surgeries
Psychiatric history Detailed social history Health maintenance
 Diagnoses/treatments  Who lives in the house  Immunizations: age- dependent
 Hospitalizations  How does the patient function on a daily basis o “DON’T ASK ARE YOUR IMMUNIZATIONS
UPTODATE”
“Be straight forward with questions” Extended family history  Screenings
“Has any one is the family had ___”  Grandparents, aunts/uncles o Pap “Actually need to know”
 Establish patterns o Mammograms
 Adopted pt doesn’t count! o Colonoscopy
 Family by marriage doesn’t count! o Cholesterol and diabetes

Comprehensive ROS
 Meant to discover symptoms that have not already been discussed
 Makes sure all systems are well-described
 May depend on the patient demographics and current health conditions  “Example: elderly pt don’t get menstrual cycle question, but do get have
you fallen recently”
 Key to asking the questions:
o Give a time frame – over the past month, 6 months, etc.
o Can start broad, then get more specific – “how is your eyesight?”, “Any trouble with your bowels? How about your bladder?”
o Go from “head to toe” or follow the list
o Negatives are just as important as positives!!!
Comprehensive physical exam
 Consider the setting – maximize patient privacy  As a student, you will never do sensitive exams unsupervised
 Examine from the top down
o Remember the separate purpose of your exam technique(s)
o Minimize patient movement
o Maximize efficiency and use of tools
o Establish your own routine – there’s no “right” order
 Documentation of comprehensive physical exam
 The order is the same as for any other type of exam
 The order you do the exam is may not be the same as the order you write it in
 Many exam techniques have dual purposes – document each purpose in its own place
o Example: for the oropharyngeal exam
 “Oropharynx clear and non-erythematous” goes under HENT
 “Palate elevates symmetrically” goes under neuro
Comprehensive H&P
 This will provide you with a lot of information about a patient.
 Practice your exam order so it feels fluid. It will eventually become muscle memory, but it takes time and lots and lots of practice.
 Minimize the number of times the patient moves.
 Pick your method so you do the same order every time so you don’t forget something.
Physical Exam: Inspect, Palpate, Percussion, and Auscultation
**Key to a through and accurate PE is developing a systematic sequence
The book recommends examining the patient from the patient’s right side, moving to the opposite side or foot of the bed
or examining table as necessary.  better jugular venous pressure, palpable right kidney more freq than left, etc
The comprehensive physical exam should proceed from the top down, concentrating on efficiency and minimizing patient position change.
Remember exam components may have a dual purpose.
Location/System Patient Exam components
position
General inspection Seated (remember to review vitals)
Observe general condition, level of consciousness, respiratory effort, and abnormal movements (tics, etc).
Skin Seated This is an ongoing element of the comprehensive exam. Inspect skin for color, consistency, turgor, lesions/rashes (if
present, describe).
Head Seated Inspect and palpate the head, palpate cranial lymph nodes (occipital, preauricular, postauricular, parotid, tonsillar,
submandibular, and submental).
ENT Seated Examine the ears, nose, and mouth/throat, test cranial nerve VIII with finger rub test or whisper test, test cranial
nerve IX, X, and XII during mouth/throat exam.
Eye Seated Inspect lids/conjunctivae, inspect and test pupils (CN II and III), test extraocular muscles (CN III, IV, VI), and compete a
funduscopic exam (coaxial or panoptic). The room should be darkened for the ophthalmoscopic exam
Cranial Nerves Seated Test cranial nerve V, VII, XI and any remaining CN you did not already test.

Neck Seated Inspect and palpate the thyroid anteriorly and posteriorly. Palpate cervical lymph nodes (anterior, posterior/deep
cervical, and supraclavicular). Auscultate the carotids (your stethoscope goes in and stays in your ears for the carotid,
heart and lung exam)
Chest Seated Auscultate the heart (4), auscultate the lungs anteriorly (4) and posteriorly (6), palpate PMI, then assess for rib
motion (3) and chest wall tenderness
Abdomen Supine Assist the patient in laying down then drape the patient. Inspect the abdomen, auscultate bowel sounds and aorta,
percuss (4), and palpate 4 quadrants with light and deep touch.
MSK Seated Test any muscle strength you need to do before the patient sits up. Assist the patient in sitting up. Inspect and
Or palpate major joints (wrist, elbow, shoulder, knees, and ankles). You can also check pulses as you check joints.
Supine Observe AROM (test PROM as needed) of the upper and lower extremity, then test muscle strength of upper and
lower extremity.
Peripheral vascular Seated Check distal pulses of radial, dorsalis pedis and posterior tibialis arteries (if not already done), test for pitting edema,
and assess perfusion status with capillary refill.
Neuro Seated Test sensation for light touch and pain, test reflexes at brachioradialis, biceps, triceps, patellar, and Achilles tendons,
Or test cerebellar function with rapid alternating movements, heal to shin, and finger to nose. Assist patient standing if
Standing needed. Assess gait with standard walking, heel, toe, and heel to toe walking. Have patient sit back done. DONE!!!
**Pt is lying on his LEFT side for the rectal exam