A History and Physical, commonly known as an H&P, is a comprehensive assessment conducted by healthcare professionals. This fundamental evaluation serves as the initial step in understanding a patient’s overall health status and forms the basis for their medical care. It provides a structured, thorough overview of a patient’s health, guiding diagnosis, treatment, and ongoing management.
Gathering the Patient’s Story
The “History” component of an H&P involves collecting subjective information directly from the patient, or sometimes from their family members. This crucial part of the assessment captures the individual’s unique narrative and perspective on their health. It begins with the Chief Complaint (CC), which is the primary reason the patient is seeking medical attention.
Following the Chief Complaint, a detailed History of Present Illness (HPI) explores the current symptoms, including their onset, duration, characteristics, and any factors that worsen or improve them. Past Medical History (PMH) includes previous illnesses, surgeries, hospitalizations, medications, and allergies.
Family History (FH) notes medical conditions in close relatives that might have a genetic component. The Social History (SH) covers lifestyle factors such as occupation, habits like smoking or alcohol consumption, and living situation, offering insights into potential health influences. A Review of Systems (ROS) systematically questions the patient about symptoms across all major body systems.
Conducting the Physical Assessment
The “Physical” component of the H&P involves the healthcare provider’s objective examination of the patient. This part focuses on observable findings and clinical signs that complement the patient’s subjective history. The examination typically begins with recording vital signs, including temperature, blood pressure, heart rate, and respiratory rate, which provide immediate physiological indicators.
A general appearance assessment notes signs of distress, nutritional status, or hygiene. A system-by-system examination is performed, involving inspecting, feeling, tapping, and listening to different parts of the body.
For example, the cardiovascular system is assessed by listening to heart sounds and checking pulses, while the respiratory system involves listening to lung sounds and observing breathing patterns. Neurological evaluation may include checking reflexes, sensation, and muscle strength. The abdomen is palpated for tenderness or abnormal masses, and the musculoskeletal system is assessed for range of motion and joint integrity.
How H&P Guides Medical Decisions
Integrating subjective information from the patient’s history with objective physical examination findings creates a complete health picture. This comprehensive data allows healthcare providers to form potential diagnoses, or differential diagnoses, by considering conditions that explain the patient’s symptoms and signs. The H&P serves as the foundation of the patient’s medical record.
This detailed assessment helps create individualized treatment plans tailored to the patient’s specific needs and health challenges. It also provides a baseline for monitoring future progress. The H&P supports decisions about necessary diagnostic tests, such as laboratory work or imaging, or if specialist referrals are warranted.
When an H&P is Performed
A medical H&P is conducted in various healthcare settings and at different stages of a patient’s care. It is a standard procedure for new patient visits to establish a baseline health record. Hospital admissions require a comprehensive H&P.
Annual physical examinations include an H&P to monitor overall health and screen for potential issues. Before surgical procedures, a pre-operative H&P is performed to identify potential risks and optimize patient safety. In urgent care settings or when a patient experiences a significant change in their health, a more focused H&P is performed, concentrating on the immediate concern. The depth and specific focus of the H&P are adjusted based on the clinical context and the patient’s needs.