Chapter 18 – How to Read a History and Physical Examination (H&P)

An H&P is a written report of a patient’s health condition. A H&P can vary in length, depending on the clinical situation and complexity of the case. The optimal length of an H&P allows the physician to clearly communicate the facts and emphasize the reliability of the information provided. The first part of the report is the chief complaint, which describes the patient’s presenting symptoms. It may be written in the patient’s words, or in the appropriate medical terminology.

Structure

The structure of a patient history and physical examination (H&P) will depend on the specific disease or illness being presented and the author’s background and experience. While the history and physical examination may not include details like coronary risk factors, the writer will become more focused with experience. Seeking feedback and reading sample write-ups will speed up the process. The core aspects of an H&P are discussed below. In addition, the sample write-ups are intended as reference standards.

Ideally, the H&P should be chronologically organized, telling the story of why the patient is seeking medical attention. The health history section should mention all relevant medical conditions, including any that may be chronic, and can be found in the patient’s opening line or past medical history. The history section should also contain any pertinent laboratory results.

Reading style

The reading style of H&P is influenced by several factors, including the type of medical record and the complexity of the case. The length of an H&P can vary widely, but it should be adequate to convey the facts of the patient’s condition. The primary goal of the write-up is to emphasize reliability and clarity of communication. The chief complaint is the main feature of the report and should be written in the patient’s own words, or in appropriate medical terminology.

How to Read History and Physicals

When reviewing a history and physical, the nurse should review the examination in light of recent information regarding the diagnosis. For example, a chest X-ray revealing a large pleural effusion should prompt the nurse to percuss the patient’s chest to hear dullness. Likewise, an echocardiogram may reveal aortic stenosis. This information can be helpful in refining technique and preparing for potential abnormal findings.

The physical examination is an essential part of interpreting a history. The results of the physical examination will confirm or disprove suspicions in the history and raise new questions. Physical examination techniques can range from simple observation to the use of a stethoscope.

A complete physical examination covers the entire body, from head to toe. It will take about 30 minutes to complete. During the exam, the examiner will check vital signs and evaluate the body using various methods. A nurse or physician may perform this physical exam according to their training and education. These methods may include examining the eyes, ears, nose, throat, skin color, and lesions. A physical examination may also involve palpation, checking organ sizes, and monitoring responses.

The patient’s medical history should be discussed during the physical examination. The nurse should be concerned about the patient’s comfort and make sure the patient feels comfortable during the exam. Prior to the physical exam, the healthcare professional will usually take the patient’s history. The medical history is an important part of a physical because it records current symptoms and any previous problems.