The History and Physical Examination, commonly referred to as the H&P, is the standardized process and foundational document in nearly all medical evaluations. It represents the clinician’s initial, comprehensive assessment of a patient’s health status, serving as the starting point for understanding their current illness and overall health profile. This methodical approach combines the patient’s narrative with observable clinical data. The H&P is systematically organized into two distinct parts: the subjective information gathered directly from the patient, and the objective data collected through the physical examination. The resulting document guides all subsequent medical decision-making, including diagnostic testing, treatment planning, and communication among the healthcare team.
The Subjective Story: Gathering the Patient’s History
The history portion of the H&P collects all subjective information reported by the patient, their family, or caregivers. This narrative begins with the Chief Complaint (CC), which is the primary reason for the visit. Following the CC is the History of Present Illness (HPI), which is the detailed, chronological story of the current symptoms. The HPI describes the onset, location, severity, duration, and any factors that make the symptoms better or worse, providing context for the central problem.
A thorough history also involves collecting biographical and contextual health information across several categories. Past Medical History (PMH) documents all prior illnesses, surgeries, hospitalizations, current medications, and known allergies. The Family History (FH) investigates the health status of immediate blood relatives to identify inherited risk factors for conditions. Social History (SH) details lifestyle factors such as occupation, living situation, and the use of tobacco, alcohol, or other substances.
Finally, the Review of Systems (ROS) methodically surveys all major body systems to uncover symptoms the patient may not have mentioned initially. This comprehensive checklist moves through areas like the cardiovascular, respiratory, and neurological systems. The data gathered provides essential context and initial probability for various diagnoses, setting the stage for the next phase of the evaluation.
The Objective Data: Performing the Physical Examination
The physical examination component is where the clinician collects objective data—information that is measurable, observable, and reproducible. This process begins with recording the patient’s Vital Signs, including temperature, heart rate, respiratory rate, and blood pressure, which offer immediate insight into the body’s physiological state. The clinician also notes the patient’s general appearance, observing their level of consciousness, posture, and overall hygiene.
The systematic physical assessment relies on four fundamental techniques: inspection, palpation, percussion, and auscultation. Inspection involves careful visual observation of the patient, looking for skin changes, swelling, or abnormal movements. Palpation uses touch to assess texture, temperature, size, and tenderness of organs or masses beneath the skin.
Percussion involves tapping specific areas of the body to produce sounds that indicate the density of the underlying tissue. Auscultation uses a stethoscope to listen to sounds generated by the heart, lungs, and bowels, allowing for the detection of abnormal rhythms or airflow. The examination then proceeds in a systematic, head-to-toe manner, assessing each body system, such as HEENT, cardiovascular, respiratory, and neurological systems.
Synthesis and Outcome: How the H&P Shapes Treatment
The H&P is not merely a collection of facts; its true value lies in the synthesis of the subjective history and the objective physical findings. This combination of the patient’s story and measurable data allows the healthcare provider to transition from information gathering to medical decision-making. The provider correlates the reported symptoms with the observed signs, such as matching a complaint of shortness of breath with objective findings.
This process leads to the formation of a working diagnosis, known as the Assessment, which includes a list of differential diagnoses. Specific details from the H&P help the clinician raise or lower the probability of each potential diagnosis, narrowing the focus. The provider then uses this assessment to formulate the Plan, which outlines the next steps.
The Plan specifies necessary diagnostic tests, such as blood work or imaging scans, needed to confirm the diagnosis or rule out alternatives. It also details the initial therapeutic steps, which may include prescribing medication, providing patient education, or arranging for follow-up care. The complete H&P document becomes a permanent part of the medical record, ensuring continuity of care and serving as a communication tool for the healthcare team.