Tuesday, July 21, 2015
Taking a proper history and physical
The history and physical (H&P) is the cornerstone of initial patient care. For those of you who are non-medical reading this, it simply means the interview and examination that occurs the first time the doctor sees their patient.
I was trained in the United Kingdom—Cardiff Medical School—to give due credit to a great institution that was big on teaching the importance of taking a complete history and performing a thorough physical examination. I'd be lying if I said my skills hadn't been diluted a bit over the years, but I always try to stick to a broad template of how to go about performing an H&P on all my patients.
At the end of my final year of residency in Baltimore, the nominated teacher of the year was our Intensive Care Unit Director, who was a quite brilliant physician. Hopkins-trained and perhaps regarded as a bit “old school”, he was my personal role model and mentor. He gave a speech at our graduation ceremony in which he said something that has always stuck with me. Offering advice on how to be a good physician, he simply said; “Do it the same way every time for all your patients.” This means you should have a systematic approach and never cut corners. I feel his words are more important today than ever, especially as the current healthcare information technology templates unfortunately now threaten to reduce the famed H&P to a pile of gabble—meaningless and incomprehensible in many ways.
So having said that, I'm going to list below the broad template of how to do a history & physical. All of this can also be found in any standard medical textbook, it's nothing new. No cut corners, don't change the order of this—as none of my Professors would allow me to:
1. chief complaint
2. history of presenting illness
3. review of systems
4. past medical history
5. past surgical history
8. family history
9. social history
1. vital signs
2. head, ears, eyes, nose, throat (HEENT), neck
7. neurological (this may come earlier if the main presenting complaint is neurological)
8. other e.g. skin, lymph nodes, joints
I would emphasize particularly to medical students, stick with the above order of things and you will seldom go wrong. Being a professional in any field means that you often have to follow set protocols and adhere to high standards. It's important as you progress in your career to keep holding yourselves to these. After all, being stringent with how you go through systematic processes will not only make you a good doctor, but also ultimately be best for your patients.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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