H & P note 2

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History and Physical Note Template

Chief Complaint or Reason for Consult: Why the patient is seeking medical care or the reason

you have been consulted.

History of Present Illness (HPI): History of present illness is the "Who, What, When, Where,

Why, How, How Long" section used to document the patient's story related to the chief

complaint or consult.

Past Medical History: A list of all medical diagnoses (include pertinent information such as a

new diagnosis). Identify the length of the diagnosis with either year or longevity.

Past Surgical History: A list of all surgeries. Be sure to include the date of the surgery.

Family History: First-degree pedigree medical diagnoses—be sure to include age and cause of

death of family members.

Social History: A synopsis of work, tobacco, alcohol, drug use, marital status, residence, travel,

functional status, and surrogate/advanced directives.

Allergies: A list of medication or food allergies and the type of reaction the patient experiences

when exposed to the foods or medications.

Home Medications: List all home medications and the dosage in milligrams and frequency.

Document adherence, including prn/over-the-counter and how often the patient takes prn

medications.

Hospital Medications: List the name, milligrams, frequency, and route if you are seeing the

patient after being admitted.

Review of Systems: Review of symptoms (told by the patient or family) but organized by

system. Must have 12 systems with at least 2 pertinent +/-

• CONSTITUTIONAL: These are the patient's answers about general constitutional signs or symptoms. Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out

functions of daily living.

• EYES: These are the patient’s answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light

sensitivity, swelling around the eyes or lids, and visual disturbances.

• EARS, NOSE, and THROAT: These are the patient's answers about signs or symptoms, including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and

abnormalities. It could include nosebleed, postnasal drip, frequent sneezing, frequent nasal drainage,

impaired ability to smell, sinus pain, difficulty breathing, or history of sinus infection and treatment. For

the throat and mouth: sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums,

history of hoarseness, change in voice quality, difficulty in swallowing or inability to taste.

• CARDIOVASCULAR: These are answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the

fingers or toes, edema, leg pain when walking.

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• RESPIRATORY: These are the patient's answers about signs or symptoms of the respiratory system. Some examples may be cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath,

difficulty breathing.

• GASTROINTESTINAL: These are patient’s answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus,

frequent nausea or vomiting, abdominal swelling, changes in bowel habits or stool characteristics, such as

diarrhea or constipation.

• GENITOURINARY: These are the patient's answers about signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank

pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile

dysfunction, irregular menses, toilet training, or bedwetting.

• MUSCULOSKELETAL: These are the patient's answers about signs or symptoms of the musculoskeletal system. Examples include muscle cramps, twitching or pain, limitations on walking, running, or

participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint

movement.

• INTEGUMENTARY: These are the patient's answers about signs or symptoms of the skin. Some examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesions, nail

color or texture, breast pain, tenderness or swelling, breast lumps, and history of nipple discharge or

changes.

• NEUROLOGICAL: These are the patient's answers about signs or symptoms of the neurologic system. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions,

memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability

to concentrate, sensory disturbances, motor disturbances, including gait, balance, and coordination, tremor,

or paralysis.

• PSYCHIATRIC: These are the patient's answers about signs or symptoms of the psychiatric system. Some examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss

of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment,

restlessness, irritability, and excessive mood swings.

• ENDOCRINE: These are the patient's answers about signs or symptoms of the endocrine system. Some examples may be blood sugar readings at home, sudden changes in height or weight, increased appetite or

thirst, intolerance to heat or cold, and changes in hair distribution or skin pigment.

• HEMATOLOGIC/LYMPHATIC: These are the patient's answers about signs or symptoms of the hematologic/lymphatic system. Examples include easy bruising, fevers which come and go, swollen glands,

night sweats, and unusual bleeding.

• ALLERGIC/IMMUNOLOGIC: These are the patient's answers about signs or symptoms of allergic/immunologic issues. Examples include answers about allergies to medication, foods or other

substances, hives or itching, frequent sneezing, chronic or clear postnasal drip, conjunctivitis, history of

chronic infection, etc.

Physical Exam: What you identify as you assess the patient.

• GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress.

• VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal

cannula, weight, and BMI.

• HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good

dentition, no lesions. Tympanic membranes are clear.

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• NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness.

• CHEST: Symmetric. Nontender to palpation.

• LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.

• HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.

• BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses.

• ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass.

• GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended

bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal.

• GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus

are normal.

• RECTAL: [Male]. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance.

• RECTAL: [Female]. Normal sphincter tone. No masses or tenderness.

• EXTREMITIES: No cyanosis, clubbing, or edema.

• NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact.

• PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect.

• SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Address surgical wounds and drains.

• LYMPHATICS: No cervical, axillary, or groin adenopathy is noted.

Laboratory and Radiology Results: List all data available when seeing the patient's normal and

abnormal results. Include all of the CBC and electrolytes (all elements tell a story).

Assessment: (Provide three references)

• Differential Diagnoses: A differential diagnosis are potential diagnoses related to the chief complaint and assessment. Provide a rationale for the working diagnosis which is

one of the differential diagnoses. Include the ICD codes. List at least three working

diagnoses related to the admission or consult and identify one as being the primary

diagnosis until ruled out.

• Acute and Chronic Medical Conditions: What needs to be addressed while admitted, in order of priority.

Treatment Plan: (Provide three references)

What orders are you starting? What medications with dose and frequency? What consults?

Education topics? Discharge plan?

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Geriatric Considerations:

Based on the age, address any differences in the treatment if the patient was younger or older.

References: List references in APA format.