Manual

"History and physical exam template"

History and physical exam template pdf

by: Paula B.
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Language: English

The History and Physical Exam, often called the "H&P" is the starting point of the is often abbreviated "CC" in the History documentation in the medical record. The written History and Physical (H&P) serves several purposes: document that provides concise information about a patient's history and exam findings at the If, for example, you were unaware that chest pain is commonly associated with. History and Physical Examination (H&P) Examples. The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations.


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The History portion contains the chronology of what is wrong with the patient - often the "what is wrong with the patient" is called the " chief complaint " and is often abbreviated "CC" in the History documentation in the medical record. For example, a patient may report that there is blood in her sputum and this has been present for a period of one week. The physician will often write: CC: "Patient reports blood in sputum for a period of one week. Following the chief complaint, the physician will also document any other pertinent History about the patient's medical, behavioral, and psycho-social aspects.

The Physical Exam includes both objective and subjective assessments of the patient's physical being. Objective medical measurements such as blood pressure , pulse rate , temperature, etc. There are also many subjective measurements made during the PE, such as visual observation and palpation , often with "best judgment" assessments as to size, location, and involvement of any abnormal finding.

For lymphoma , involvement of lymph nodes matted nodes, fixed vs. For central nervous system tumors, neurologic examination for signs and symptoms which help identify the location of the tumor ; vision changes; attention deficit; focal deficit blindness, taste aberrations ; tumor impingement on a specific nerve or structure; mass effect light-headedness, loss of vision ; evidence of increased intracranial pressure edema , headache , nausea and vomiting ; evidence of obstructive hydrocephalus.

Manual or digital examination of the lower portion of the rectum , perineum and surrounding tissues using a gloved finger inserted into the anus. During the examination, the examining finger can feel the prostate gland. Also called DRE , rectal exam, manual exam. Masses and enlarged organs organomegaly; hepatomegaly; splenomegaly ; palpable lymph nodes; jaundice yellowing of skin and eyes due to blockage of bile ducts. Manual or speculum evaluation of cervix , vagina , rectum, external genitalia.

Digital examination of the rectum and vagina is also called a rectovaginal exam. Visualization of clinically accessible areas of the head and neck by viewing them in a mirror or through an endoscope see also Endoscopies.

A test to determine any defects in the patient's vision, which in turn may reveal the location of a brain tumor. Visual field alterations caused by problems in different brain sites are unique.

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A Physical Exam or a Physical Assessment is an important means of preventive medicine for everyone regardless of race, age, sex, or level of activity. Physical Examinations are a means to screen for a disease, an ailment, or a condition and enables medical practitioners to assess its future medical risk. A Physical Examination is a process wherein a medical practitioner goes through the body of a patient and checks for any sign of disease.

Physical Exams are recommended for everyone, especially among individuals above the age of Annual Physical Exams help in identifying issues that may be a cause for concern in the future, a means to update any necessary immunizations, and helps to ensure a healthy diet and exercise routine.

Routine Physical Examinations are assessments typically performed on asymptomatic patients. Asymptomatic means that the patient does not harbor any symptoms of illness or disease. Routine Exams are usually done for screening purposes and are normally conducted by pediatrician, physician, primary care providers, and a certified nurse. Pre-employment Physical Examinations are typically conducted to screen employees and to determine their suitability to work based on the results of the Physical Examination.

Pre-employment Physical Exams are usually required by employers to make sure that an employee for hire is physically capable of performing his job and coming to work. These types of exam assure employees that the employee will have fewer absences due to sickness, fewer workplace injuries, and a low rate of occupational disease.

Comprehensive Physical Examinations normally include laboratory tests, chest x-rays, full body CAT scans, EKGs, pulmonary tests, urinalysis, and mammograms or prostate exams. Insurance Physical Exams are assessments done when purchasing health or life insurance. This type of exam helps in determining the safety aspects of a candidate to participate in a certain sport.

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Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin. PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress. A Physical Exam or a Physical Assessment is an important means of preventive medicine for everyone regardless of race, age, sex, or level of activity. Physical Examinations are a means to screen for a disease, an ailment, or a condition and enables medical practitioners to assess its future medical risk. 1 THE HISTORY AND PHYSICAL (H & P) I. Chief Complaint Why the patient came to the hospital Should be written in the patient's own words II. History of Present Illness (HPI) a chronologic account of the major problem for which the patient is seeking medical care.