THE HISTORY
Note: the write-ups that are turned in to the preceptor should be
no longer than 5-6 pages in length; limit your discussion to ½-1
page focusing on an indepth question stimulated by your patient
and their illness.
Identify Informant
Reliability of Informant
Chief Complaint:
This is a statement in the informant’s own words of the
symptoms which brought him/her to medical attention. The chief
complaint should orient the reader to the rest of the H&P.
Consider it akin to the title to an essay.
“Chief complaint: ‘Pain in my chest and difficulty breathing for
two weeks’”.
Occasionally patients are hospitalized for evaluation of a specific
physical or laboratory finding rather than because of a chief
complaint. In these instances the record should state the
findings as the basis for admission to the hospital.
History of Present Illness:
This is the heart of the narrative. A good history and a wellconstructed HPI should lead the listener/reader to the correct
diagnosis much of the time. The HPI should contain all the
historical elements that you consider to be pertinent to this
presentation (from medications, allergies, PMH, PSxH, SH, FH, or
ROS). The HPI and CC can really only be written after you
develop your own impression about what the case is about.
Avoid abbreviations and jargon. Write short, clear declarative
sentences that are easily comprehended on the first reading. For
models of clarity on how to write up a case, refer to the weekly
Clinical Pathological Cases (CPC) in the New England Journal of
Medicine.
The first sentence of the HPI should contain the patient’s age,
gender, major role/occupation, and a brief list of pertinent
diagnoses in order of importance. For example, “The patient is a
65 yo retired school-teacher with a history of coronary artery
disease, chronic obstructive pulmonary disease and GERD.” You
may decide not to include the fact that the patient also has a
history of benign prostatic hypertrophy if you do not think if
pertinent to the HPI.
The HPI should be told chronologically, beginning with the first
symptom or sign that can reasonably be ascribed to the
problem. Each major symptom should then be described, giving
its time of onset, course of development and present status. You
may choose a mnemonic such as OLD CARTS (onset, location,
duration, character, aggravating/alleviating factors, radiation,
timing, and severity from 1-10). Medications and other
treatments employed during the present illness should be
identified.
After the bulk of the present illness is described, a section of
pertinent negative review of systems should be listed. For
instance, if the patient presents with chest pain, the ultimate
impression might be community-acquired pneumonia, but the
differential might also include myocardial infarction and
pulmonary embolism. At the end of the review of systems, you
might write
“Patient denies radiating pain, nausea, palpitations. The patient
also denies recent travel or immobility, history of blood clots, or
recent lower extremity edema.”
If there are two or more unrelated problems that are
part of the presenting illness, each should be described
separately in appropriate chronological sequence.
At the end of the HPI, you may also choose to briefly describe
the EMS and emergency department course. For the purposes of
the teaching, note that some attendings will not want you to
deliver this section when presenting the oral case presentation;
others will want to hear it. In this section, the pertinent history,
physical exam, and data should be presented in broad
brushstrokes. For instance, in a chest pain admission, you might
write the following:
“EMS was called and found the patient holding his chest and
with labored breathing. His vitals were: BP 190/95, P 96, RR 22.
Pt was given ASA 325 on route to the hospital. Once the patient
was in the ER, the patient was still complaining of 4/10
substernal chest pain. Vitals showed T 98F, BP of 190/100, P 90,
RR 22. Pulse Oximetry showed O2 sat: 88%. The ED attending
also noted moderate labored breathing, elevated IJ pulsation,
bibasilar rales, and an S3. The initial set of labs revealed a normal
troponin I and EKG without any signs of ischemia. CXR showed
pulmonary vascular congestion. The initial impression was
hypertensive emergency with pulmonary edema. The patient was
given Lasix 80 mg IV with 1L urine output over an hour and with
moderate improvement of respiratory and chest complaints.”
Past Medical History:
1. Diagnoses: Enumerate each diagnosis in order of
importance. For each diagnosis, list date of diagnosis,
overall state of control/management, presence of any
complications, and any pertinent associated history/data.
Always get as much direct evidence and information as
possible! Make sure to note any hospitalizations or ER visits
pertaining to any diagnosis.
2. PMD and specialists. Here, list the patient’s primary care
doctor and any specialists he/she has seen with telephone
numbers.
Past Surgical History: List and enumerate the type of surgery,
year, and hospital where performed if pertinent (for instance, this
information may help the team obtain records if it is deemed
important).
Medications: List medications, doses, and frequency. Use
generic names. List any herbal remedies, supplements or overthe-counter medicines. Make note of adherence.
Allergies: List the medication or class of medications and the
reaction that it elicits.
Immunizations:
Social History:
1. Marital Status: health of spouse, children.
2. Education and Occupation: trade, exposure. If retired or
otherwise not working, what work previously? Level of
education attained.
3. Habits: tobacco, alcohol, diet, non-prescribed and illicit
drugs ( be specific about type: heroin, methadone,
marijuana, LSD, cocaine, and other addicting or habituating
agents); list quantity, frequency, and duration of use.
Exercise habits. CAGE questions. Quit attempts and
motivation to change.
4. Birth place, when move/come to US? travel history
including areas of the U.S. that have special types of
contagion.
5. Present Environment: support system, where does the
patient live, with whom, stairs required, pets. Domestic
violence screening questions.
6. Financial: general, medical and hospital insurance.
7. Kleinmann questions:
What do you call the problem? What do you think caused the
problem? Why do you think it started when it did? What do you
think the sickness does? How does it work? How severe is the
sickness and will it have a short of long course? What kind of
treatment do you think you should receive? What are the most
important results you hope to receive from the treatment? What
are the chief problems the sickness has caused? What do you
fear most about the sickness?
1. Sexual history: emphasize that this will remain confidential
and for medical care use only; sex with men, women, or
both? Use of barrier protection/condoms? History of sexual
transmitted infections in self or partners and history of
treatment.
2. Goals of care/ health care proxy: this may be especially
pertinent for patients near the end of life.
Family History:
List parents and siblings with age, state of health or age at
death. Inquire about illnesses relating to patient’s problem.
Illnesses with known familial tendencies can sometimes best be
diagrammed.
Conclude the history with an open-ended question such as: “Is
there anything else in your past or present medical history we
should talk about?”
Review of Systems:
Include symptoms the patient has been experiencing over the
past several weeks/months. If these symptoms are pertinent to
the HPI, they should be presented in that section, not in the ROS.
As you actually obtain the history, you may choose to use the
structure of the ROS to remember to ask about pertinent
diagnoses related to a system. For instance, for the patient
presenting with shortness of breath, when preparing to ask about
the pulmonary ROS, you may also choose to ask the following,
“Have you had any lung diseases -- for instance, asthma or
emphysema?” If you get a positive response to this question,
note that it will be listed in the PMH section, not in the ROS.
Although you may want to use a template to be comprehensive,
tailor your ROS to the patient: include questions about ageappropriate screening tests, relevant gynecologic or urologic
questions, or for example, go into more detail about symptoms
that might suggest a paraneoplastic syndrome in the patient with
cancer, or symptoms that would suggest complications in a
diabetic.
1. Constitutional: fevers, sweats, rigors, weight loss or gain (if
so, quantify), “energy” level, sleep
2. HEENT:
Headache: frequency, duration, response to treatment.
Eyes: vision, glasses, date of last examination, diplopia,
inflammation, pain.
Ears: hearing, tinnitus.
Nose: epistaxis, obstruction.
Oropharynx/dental: hoarseness, sore throat, sinus problems,
teeth and gums.
1. Respiratory: shortness of breath, pleuritic chest pain, cough,
sputum (description), wheezing, hemoptysis
2. Cardiac: chest pain, orthopnea, paroxysmal nocturnal
dyspnea, palpitations, peripheral edema, lightheadedness;
changes in exercise tolerance or duration; You may want to
ask about factors for arteriosclerotic cardiovascular disease
(i.e., hypertension, diabetes mellitus, family Hx, cigarette
smoking, hyperlipidemia) but list in PMH or HPI if positive/
pertinent to complaint.
3. Vascular Disease: exertional limb pain (claudication),
extremity swelling, cold feet, skin changes in feet,
4. Gastro-intestinal: appetite, change in PO intake, swallowing
difficulty or pain (dysphagia/odynophagia), digestion,
heartburn, nausea, vomiting (if +, color, frequency, amount),
hematemesis (vomiting of blood), change in bowel habits,
color of stool, diarrhea (if +, color, frequency, amount), blood
in stool or black colored stool (melena), abdominal pain
5. Genito-urinary: dysuria (pain with urination), nocturia (if +,
quantify), hematuria, polyuria, trouble passing urine (in men,
hesitancy or incomplete voiding), urinary incontinence (with
coughing/laughing or with increased urge to urinate).
Erectile dysfunction, change in sexual desire
6. Gyn: pain with or change in frequency/timing/quantity of
menstrual bleeding, vaginal discharge, pain with intercourse
(dyspareunia)
7. Neuro: loss of consciousness, vertigo, tremors, syncope,
loss of coordination, weakness, memory changes,
numbness, tingling (parasthesias) or radiating pain
8. Psychiatric: depressed mood, anhedonia, anxiety, irritability,
trouble concentrating (if any +, suicidal ideation, auditory
hallucinations); prior psychiatric treatment
9. Hematological: bleeding or clotting problems (nose bleeds
or heavy/prolonged menses), easy bruising
10. Musculoskeletal: joint pain, swelling, morning joint stiffness,
back pain
11. Endocrine: polyuria, polyphagia, polydipsia; heat or cold
tolerance.
12. Dermatological: rashes, pruritus.
THE PHYSICAL EXAMINATION
This is a description of an extensive physical exam, but by no
means comprehensive. Some of the exam below may not pertain
to the patient in front of you, and in other situations you may be
expected to perform additional maneuvers or provide greater
description of the system or part of body involved. For example,
if a patient presents with abdominal pain, a complete
neurological exam might not be expected, yet a rectal exam to
evaluate for stool in the colon and a pelvic exam to evaluate for
cervical motion tenderness or adnexal masses should be
included.
1. Vital Signs
Temperature, Pulse, Respiration, Blood Pressure (arm, R or L;
position), weight, height and BMI (kg/m2)
1. General Appearance
General survey: apparent state of health, state of nutrition,
development, signs of distress; gait; color of skin and mucous
membrane; dyspnea; orthopnea; edema; mental condition,
affect. The skin should be described noting texture, rashes,
pigmentation and hair distribution.
1. Head
Eyes: vision, movement, gross visual fields, conjunctivae and
sclerae; pupils-size, reaction, equality; appearance of fundi;
corneal sensitivity.
Ears: hearing; air and bone conduction; discharge; appearance of
tympanic membranes; movement of membranes; tophi; coronary
crease.
Nose: obstruction to breathing; septal deviation and/or
perforation; discharge.
Mouth: sores; dental status; appearance and palpation of
muscosa, tongue, gums, floor of mouth; appearance of tonsils,
pharynx; appearance and movement of uvula, palate; gag reflex.
1. Neck
Palpable masses; thyroid; location of trachea; venous
engorgement; bruits; flexibility.
1. Lymph Nodes
Enlargement, consistency and/or tenderness of cervical, axillary,
epitrochlear, popliteal, and inguinal glands.
1. Chest
Appearance and function of chest wall
Breasts: appearance, asymmetry, tenderness, masses, nipple
discharge.
Lungs: type of respiration, percussion note, diaphragm
movements, character of breath sounds; presence of rales,
rhonchi, wheezes or rubs; post-tussive rales.
1. Heart
Apex location, precordial movements
Palpation & Percussion: location of cardiac borders, thrills,
shocks, heaves, palpable sounds, carotid and jugular pulse wave
characteristics.
Auscultation: heart sounds; S1, S2, S3, S4; presence of
murmurs, clicks, rub, split sounds; effect of respiration, change in
position & maneuvers on murmurs and sounds; radiation of
murmurs.
Pulses: carotids, brachials, radials, femorals, dorsalis pedis,
posterior tibials.
1. Spine
Mobility, tenderness, curvature
1. Abdomen
Appearance (distended, flat, scaphoid), abnormal movements,
dilated veins, striae, scars.
Auscultation: bowel sounds, bruits, rubs.
Percussion: distension, organ size (liver, spleen, bladder), shifting
dullness, measure liver size in MCL in cm.
Palpation: resistance, tenderness, rebound, organs (liver, spleen,
kidney), masses, epigastric or incisional hernia.
1. Extremities
Skin color, temperature, texture, varicosities, clubbing, edema,
joint motions, muscle mass/wasting, circumference.
1. Neurological
Mental status, cranial nerves, cerebellar function, muscle
strength, reflexes, gait and station, rapid sensory exam including
vibratory.
1. Genitalia
Discharge, sores, or scars, hydrocele, varicocele, testicular
masses; inguinal and femoral herniae.
Pelvic examination: inspection and palpation of vulva and
perineum, evaluation of perineal and vaginal supports,
preparation of Papanicolaou smear, visualization of vaginal walls
and cervix, bimanual palpation of uterus and adnexa.
1. Rectal
Hemorrhoids, sphincter tone, prostate, masses, gross blood or
Hematest, Note color of stool.
Laboratory Data:
Record CBC & differential, basic metabolic, hepatic function
tests, urinalysis, chest X-ray, ECG, and others when appropriate
(e.g. arterial blood gases, amylase, prothrombin time, cultures).
Please specify whose reading of the EKG and imaging studies
you list: your own, or someone else’s.
Formulation:
This should be a several sentence summary of major positive and
pertinent negative findings from the history and physical
examination. Significant laboratory data should also be noted.
Briefly indicate any social or psychological problems that may
present a major and immediate obstacle to treatment or
recovery. This is the foundation upon which the diagnostic
possibilities and therapeutic plans will be based. The possible
interrelationships of these findings and the nature of the
disordered pathophysiology should be summarized.
If possible, do not simply list information, but offer an
interpretation. This will require you to make some judgments
regarding which symptoms and sign are relevant to the
diagnosis, and which may be unrelated.“ For example: “This 60
year old married, high school English teacher and father of two
presents with three weeks of constitutional symptoms including
weight loss and fever, a new murmur of mitral regurgitation,
splenomegaly, multiple splinter hemorrhages, elevated WBC
count with a left shift, normocytic normochromic anemia, and
ESR of 100 all of which suggests a diagnosis of subacute
bacterial endocarditis. Other infectious, malignant and
rheumatologic etiologies of his symptoms should also be
considered.”
Impression (aka Assessment):
List the major diagnostic possibilities considered likely
explanations for the abnormal findings and provide supporting
data for and against each diagnosis. Be sure to address the most
likely possibilities as well as the most serious and life
threatening. Even if unlikely these should be considered and
excluded. Consider the following when tackling the most
challenging differentials:
•
•
•
Challenge your initial impression about when the illness
began: for instance, in the example above, if this patient had
a previous history of rheumatic heart disease or known
valvular heart disease, that would be important to note
Build your differential around the pivot, or pivots: the
cardinal feature(s) of the illness that are certain not to be red
herrings
Consider all categories of etiologies: some like mnemonics
such as this one:
V – Vascular
I – Infectious
T – Trauma
A – Autoimmune
M – Metabolic/ Toxic
I – Idiopathic
N – Neoplastic, Nutritional
C - Congentital/hereditary
•
•
•
Think chronologically and pathophysiologically about how a
sequence of events might have led to the presentation.
In addition to the most likely explanations, always consider
the possible worst-case scenarios: the most serious or most
life threatening diagnoses
Where there are several significant problems, these should
be listed sequentially and each discussed similarly.
Plan:
Use a prioritized problem oriented list rather than a system based
approach and list the evaluation and diagnostic strategy
proposed for each problem. Do so being thoughtful about what
you will do with the outcomes of diagnostic tests (prior and
posterior probability) and try to formulate your list in order of
priority so that the most important tests get done first. Always
include important psychosocial aspects of the patients care;
goals of care; and think ahead to follow up care.
Discussion (1/2 pg):
Formulate a question related to the patient’s illness, the
underlying basic mechanisms of disease, or treatment, effective
testing (prior probability, sensitivity and specificity) or decision
analysis and discuss your topic relative to the patient’s
specific circumstances. This should not be a review of a
general topic or presenting symptom but driven by your need to
understand your patient in particular in greater depth.
Signature: ___________________________ (CCs, CC4, M.D.)
Date: ______________________________