Components of the Comprehensive Adult History and Physical Write Up

Identifying ˆ Age, gender, occupation, marital status (race if clinically relevant)

Data
ˆ If the patient is not the source of the information state who is and if the patient is not
Source and considered reliable explain why (for example “intoxicated” or “somnolent”)
Reliability
ˆ Include the one or more symptoms causing the patient to seek care. This should be in
The Chief the patient’s words. For example, “My back hurts and I am afraid it is cancer,” or
Complaint “my wife sent me in for a yearly check up.”
History of ˆ This is an amplification of the chief complaint.
Present Illness ˆ Describe how each symptom developed in a chronologic and organized manner.
ˆ Address why the patient is seeking attention at this time. For example, the pain was
severe, the patient could no longer work or the patient was referred from another
physician’s office.
ˆ Include the 7 dimensions of each symptom. You can remember “LOCATES” and
include (listed more logically) location, quality or character, quantity or severity,
timing (onset, duration and frequency), setting in which symptoms occur,
aggravating and alleviating factors and associated symptoms.
ˆ Include the patient’s thoughts and feelings about the about the illness.
ˆ Incorporate elements of PMH, FH, SH that are relevant to story. For example for a
patient with chest pain include the patient’s history of diabetes, hypertension and
hyperlipidemia and smoking and a family history of death from coronary artery
disease at an early age (under 60 for a female and under 50 for a male relative).
ˆ Include pertinent positives and negatives based on relevant portions of the ROS. If
included here these elements do not need to be repeated in the ROS.
ˆ The HPI should set the stage for the differential diagnosis you will present in your
assessment and plan.
Past Medical ˆ Describe any significant childhood illnesses.
History ˆ Describe adult medical illnesses with additional detail such as date of onset,
hospitalizations, complications and if relevant, treatments. For example, “Type 2
diabetes mellitus since age 53 with a history of retinopathy and multiple successful
laser treatments.”
ˆ Surgical history with dates, indications and types of operations.
ˆ OB/Gyn history with obstetric history, menstrual history, birth control, sexual
preference.
ˆ Psychiatric history with dates, diagnoses, hospitalizations and treatments.
ˆ Is the patient up to date on appropriate health maintenance (pap smears,
mammogram, cholesterol testing, colonoscopy, etc) and immunizations?
Medications ˆ For each medication include dose, route, frequency and generic name.
ˆ Include over the counter medications, supplements and “PRN” or, as needed,
medications.
Allergies ˆ Describe the nature of the adverse reaction.
Review of ˆ Let the patient know you are going to ask questions from “head to toe.”
Systems ˆ Start with a general question about that system then get more specific.
ˆ As you stimulate the patient’s memory with your questions you may uncover
elements related to the HPI or that really belong in the Past Medical History at this
time. Move these elements where they belong. Do not keep them in the ROS section
in your write up.
ˆ See the “Medical Information Systems: Adult History and Physical Exam”
laminated card, available in the book store, or pages ** in Bates for a detailed list of
symptoms
Social History ˆ Include occupation, highest level of education, home situation and significant others.
ˆ Include any important life experiences such as military service, religious affiliation
and spiritual beliefs.
ˆ Assess the patient’s functional status: his or her ability to complete the activities of
daily living independently.
ˆ Quantify any tobacco, alcohol or drug use.
Family ˆ Comment on the state of health or cause of death of parents, siblings, children and
History grandparents.
ˆ Record the presence of the following of any unusual diseases that run in the family or
the following common hereditary conditions: hypertension, coronary artery disease,
stroke, diabetes, cancer, kidney disease, thyroid disease, asthma, mental illness, and
alcohol or drug addiction.
Physical ˆ Be sure to include a general description (so that the patient could be
Examination “Picked out of a line up.”)
ˆ Don’t forget vital signs including weight, height, calculated body mass index, blood
pressure, pulse, temperature and respiratory rate.
ˆ Make sure that the PE is complete and includes the areas relevant to the chief
complaint.
ˆ Avoid vague descriptions such as “normal.”
ˆ For more detail see the physical exam checklist
Data ˆ Include lab data appropriate for the HPI.
Collection ˆ Provide appropriate descriptions of findings (not “EKG normal”)
Problem List ˆ Make a complete list of the patient’s active problems.
ˆ Present the list in prioritized order.
Assessment ˆ Identify the patient’s abnormal symptoms and signs.
ˆ Try to localize the symptoms and signs anatomically.
ˆ Interpret these findings in terms of the probable process.
ˆ Make hypotheses about the nature of the patient’s problems.
ˆ Decide what further information you will need to test the hypotheses. For example,
obtain more history, or order x-rays or lab studies.
Plan ˆ Identify a plan for each patient problem. This can include testing, treatment,
observation, patient education, family meeting or referral to subspecialty evaluation.
Format ˆ Be sure your write up is legible and well written.
ˆ Avoid spelling or grammatical errors
ˆ Use only commonly accepted abbreviations
General ˆ Be concise and avoid redundancy.
ˆ All of your thought processes should be communicated in a logical and well-
organized manner
HIPAA ˆ Remove patient identification from your write up.