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complete history and physical examination template
the history and physical exam, often called the “h&p” is the starting point of the patient’s “story” as to why they sought medical attention or are now receiving medical attention. the physician will often write: cc: “patient reports blood in sputum for a period of one week.” the physical exam includes both objective and subjective assessments of the patient’s physical being. 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.
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. other words/no involvement: if there is no mention of prostatic abnormality during the exam; benign prostatic hypertrophy. digital examination of the rectum and vagina is also called a rectovaginal exam.
the links below are to actual handps written by unc students during their inpatient clerkship rotations. the students have granted permission to have these handps insomnia. objective (physical exam – sample recordings) vital signs and general appearance: age, sex, well developed/nourished, appears stated age, nad. (sample summative handp by m2 student) this sample summative handp was written by a second‐year medical student at the time of the physical exam, the., sample written history and physical examination, sample written history and physical examination, medical history sample cases, history and physical template word, physical exam template for medical students
complete history and physical examination template format
while this has traditionally been referred to as the chief complaint, chief concern may be a better description as it is less pejorative and confrontational sounding. this format is easy to read and makes bytes of chronological information readily apparent to the reader. a brief review of systems related to the current complaint is generally noted at the end of the hpi. when dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the hpi. also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. so, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.
pertinent positives and negatives related to the chief concern) are generally noted at the end of the hpi. the swelling was accompanied by a weight gain of 10lb in 2 days (175 to 185lb) as well as a decrease in his exercise tolerance. he now becomes dyspneic when rising to get out of bed and has to rest due to sob when walking on flat ground. onset was abrupt and he first noted this when he “couldn’t see the clock” while at a restaurant. over the past few days he has noted increased dyspnea, wheezing, and sputum production. story of the sudden onset of neurologic deficits while awake, in the setting of newly identified atrial fibrillation, is most consistent with a cardio-embolic event. of note, as last known normal was > 24 hours ago, he is outside the window to receive tpa or device driven therapy.
example of a complete history and physical write-up hypertension who presented with the chief complaint of substernal “toothache like” physical exam. 1. the history and physical exam, often called the “handp” is the starting point of the for example, a patient may report that there is blood in her sputum and this according to bates’ a guide to physical examination, the present illness pain, change in ability to smell, sneezing, post-nasal drip, history of nasal polyps for example: “cr nn iii, iv, and vi: full eom’s; intact direct and consensual pupillary , medical history sample cases pdf, history and physical examination pdf, history and physical examination pdf, comprehensive health assessment paper example, physical exam template word, sample written history and physical examination, medical history sample cases, history and physical template word, physical exam template for medical students, medical history sample cases pdf, history and physical examination pdf, comprehensive health assessment paper example, physical exam template word
complete history and physical examination template download
the patient is a 50-year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago. she rates the pain as 7 or 8 on a scale of 1 to 10, with 10 being the worst possible headache. she is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days. her maternal grandfather had a stroke at age 69. there is no other family history of stroke or vascular disease, but she has no information about her father’s side of the family. mental status: the patient is alert, attentive, and oriented. when the patient is looking to the left, the right eye does not adduct.
there is ptosis of the right eye. tandem gait is normal when the patient closes one of her eyes. ophthalmoplegic migraine remains a likely diagnosis given the history of migraine with aura, even though the current headache is different in character from her usual headaches and is not associated with visual aura, nausea/vomiting, or photophobia. so the fact that her pupil is normal in size and reactive to light weighs against the diagnosis of a compressive lesion such as an aneurysm or tumor, but does not eliminate the possibility. the patient denies a history of hypertension, is not currently hypertensive, and has no risk factors for vascular disease, but the possibility of a genetic disorder such as cadasil cannot be excluded given the lack of paternal history. if the cerebral angiogram and lumbar puncture are negative and her headache does not improve, she may be a candidate for iv dihydroergotamine treatment.