History and Physical Examination Writing

The History and Physical Examination (H&P) is the cornerstone document of clinical medicine, serving as both a diagnostic roadmap and a critical legal and communication tool. Your ability to write a detailed, organized, and insightful H&P directly reflects your clinical reasoning and is fundamental to safe, effective patient care. Mastering this skill transforms you from a passive observer into an active clinician, capable of synthesizing a patient's story and findings into a coherent narrative that guides the entire medical team.

The Foundation: Chief Complaint and History of Present Illness

The chief complaint (CC) is a succinct statement in the patient's own words, describing the primary reason for their visit. It anchors the entire document. For example: "My chest feels tight when I walk," not "Patient presents with angina."

The History of Present Illness (HPI) is the narrative core of the H&P. This is where you demonstrate your diagnostic thinking. A well-organized HPI is a chronologic, detailed story of the CC. Use the OPQRST mnemonic to ensure completeness: Onset (sudden vs. gradual), Provocation/Palliation (what makes it better or worse), Quality (aching, sharp, pressure), Radiation, Severity (on a 1-10 scale), and Timing (constant, intermittent, duration). Crucially, you must also document pertinent positives and negatives—symptoms that support or refute potential diagnoses on your differential. For instance, for chest pain, pertinent negatives would include "no shortness of breath, no diaphoresis, no nausea."

Building the Context: Past History, Family History, and Social History

A patient's past provides essential context for their present illness. The Past Medical History (PMH) includes all chronic conditions (e.g., hypertension, diabetes), past acute illnesses, and hospitalizations. The Past Surgical History (PSH) lists procedures with dates and indications. Medications, including over-the-counter drugs and supplements, must be listed with dosages. Allergies must be documented with the specific reaction (e.g., "penicillin: hives").

The Family History (FH) focuses on heritable conditions in first- and second-degree relatives, noting age of onset if known. This can reveal risk factors for diseases like coronary artery disease, cancer, or diabetes.

The Social History (SH) is not a mere formality; it paints a picture of the patient's life and risk factors. It includes occupation, tobacco/alcohol/substance use (quantified, e.g., "20 pack-year smoking history"), sexual activity, living situation, and diet/exercise habits. This section is vital for understanding psychosocial barriers to care and tailoring treatment plans.

The Systematic Review and Physical Examination

The Review of Systems (ROS) is a head-to-toe inventory of symptoms, both related and unrelated to the CC. It acts as a safety net to uncover hidden problems. While a comprehensive ROS is ideal, a focused ROS centered on the HPI system and related systems is often appropriate for clinical efficiency. Document pertinent positives and negatives clearly (e.g., "Constitutional: No fever or unintentional weight loss. GI: Denies nausea, vomiting, or melena").

The Physical Examination (PE) must be objective and systematic. Begin with Vital Signs: temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Document your findings using standard clinical language. Avoid judgments like "normal lungs." Instead, write: "Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi." Organize by system: General Appearance, HEENT (Head, Eyes, Ears, Nose, Throat), Neck, Cardiovascular, Pulmonary, Abdomen, Extremities, Neurological, Skin. Findings should be recorded as observed, not interpreted (save interpretation for the Assessment).

Synthesis: Assessment and Plan

This is the culmination of your diagnostic work. The Assessment is a concise summary statement that synthesizes the key data. For a new problem, it often begins: "This is a [patient age]-year-old with a past medical history of [X] presenting with [chief complaint], most likely secondary to [primary diagnosis]." You then list the Differential Diagnosis, ranking possibilities from most to least likely. For established problems, list each active medical issue as a separate, numbered problem.

The Plan corresponds directly to each numbered problem in the Assessment. It is the actionable blueprint for care. For Problem #1 (e.g., "Community-Acquired Pneumonia"), the plan should be specific and follow a logical sequence: Diagnostic (e.g., "CXR, CBC, blood cultures"), Therapeutic (e.g., "Start ceftriaxone and azithromycin"), and Patient Education/Disposition (e.g., "Admit to medical floor for IV antibiotics and monitoring"). This structure ensures nothing is missed and communicates your reasoning clearly to other providers.

Common Pitfalls

Writing a Disorganized or Vague HPI: A scattered timeline or failure to use OPQRST leads to a confusing story. Correction: Always begin with the onset and narrate the story forward. Explicitly include pertinent positives/negatives that shaped your thinking. For example, instead of "had pain for a week," write: "Sharp, right-sided abdominal pain began 7 days ago, is worse after eating fatty foods (positive), but no fever or jaundice (negative)."

Omitting Critical Social History or Medications: Listing "denies tobacco use" is insufficient if you don't ask about vaping or a remote 30-pack-year history. Similarly, documenting "on water pill" instead of "Hydrochlorothiazide 25 mg daily" is dangerously vague. Correction: Be specific and quantitative. Ask open-ended questions: "Tell me about any tobacco, vaping, or nicotine use in your lifetime." Verify medication names and dosages against the bottle or pharmacy list.

Confusing Subjective Reporting with Objective Findings: Stating "abdomen tender to palpation" in the HPI mixes the patient's symptom (subjective pain) with your exam finding (objective tenderness). Correction: Keep domains separate. The patient's report of "stomach pain" belongs in the HPI. Your finding of "tenderness in the right lower quadrant" belongs in the Physical Exam.

Creating a Weak or Disconnected Assessment & Plan: A plan that simply says "follow up" or "continue meds" lacks clinical utility. A differential diagnosis with only one item shows inadequate consideration. Correction: Your assessment should justify your leading diagnosis based on HPI and PE findings. Your plan must be itemized (Diagnostics/Therapeutics/Education) and directly linked to each problem. For the differential, always consider at least 2-3 plausible possibilities.

Summary

• The H&P is a structured, logical argument that moves from the patient's subjective story (HPI) to your objective findings (PE) and culminates in a synthesized Assessment and actionable Plan.
• The History of Present Illness is a chronologic narrative, enriched by the OPQRST framework and pertinent positives/negatives, which demonstrates your clinical reasoning.
• Past Medical, Surgical, Family, and Social Histories provide essential diagnostic context and are critical for creating a safe, personalized treatment plan.
• The Physical Exam must be recorded using precise, objective language, separating findings from interpretation.
• The Assessment and Plan is the payoff of your work; it should feature a ranked differential diagnosis and a problem-specific plan covering diagnostic, therapeutic, and educational interventions.