Understanding the History and Physical of Admitted Patients: What You Need to Know

It is important to read and understand the history and physical when you are caring for your intensive care patient. This document is used by you and the providers to track the patient’s health and diagnose any potential problems. When you are reviewing your patient’s chart before the shift, this is an important document to look through when you are looking at the patient as a whole.

We will discuss what information is included in a history and physical, and how it can help you provide your patient with the best possible care.

Table of Contents

What is a history and physical?

A history and physical (H&P) is a medical document that contains information about a patient’s current health condition upon admission. It includes information about the patient’s chief complaint, history of present illness/symptoms, medical history, surgical history, social history, family history, allergies, any current medications, review of systems/physical examination, pertinent diagnostic tests, assessment, and plan.

The H&P is important because it gives the providers a baseline of the patient’s health upon admission. This document is used to track the patient’s progress and any changes in their condition. It is also used to help diagnose any potential problems.

medical history

What information is included in the history and physical?

Chief Complaint

The chief complaint is the reason why the patient is seeking medical attention. It is typically expressed in the patient’s own words.

Chief Complaint: new onset fever, hypertension, rigidity, and altered mental status

History of Present Illness/Symptoms

The history of present illness (HPI) is a chronological account of the patient’s symptoms. It includes information about the patient’s symptoms, when they started, how long they have been going on, any changes in the severity of the symptoms, and any other relevant information.

HPI: Mr. Smith is a pleasant 80-year-old male with a history of dementia, hearing loss, and hypertension who was admitted to the intensive care unit on 9/1 for aggressive behavior, altered mental status, and hypertensive crisis. The patient’s primary provider has been adjusting medications for his dementia and hypertension to help alleviate symptoms without success per family. Mr. Smith is a resident of Happy Pines Nursing Home and has had multiple events of aggression and hypertension. Mr. Smith developed a non-productive cough prior to admission and refused to eat due to body rigidity following the cough. Rigidity began to rise after spiking a fever of 102.9 and lasted for 45 minutes. Mr. Smith was transferred to ABC hospital where his hypertension continued to increase and he no longer responded to verbal or painful stimuli. Mr. Smith was no longer responsive prior to being transferred to intensive care.

A general medical assessment was completed and a sepsis workup was started in the Emergency Department. Blood cultures x2 were collected along with initial labs including CBC, cardiac enzymes, and chemistries. Serial vital signs were ordered and Dantrolene was administered STAT. Vital signs were T 102.8, HR 130, RR 22, and BP 220/110 at 1800. Breathing improved after suctioning and elevation of the head of the bed.

Medical History

The medical history is a summary of the patient’s past medical problems. This includes information about any chronic conditions, hospitalizations, and any other relevant information.

Past Medical History:

  1. Hypertension
  2. Dementia – diagnosed in 2010 and is followed up by Dr. David
  3. Hearing loss – patient wears hearing aids in both ears
  4. COPD
  5. Anxiety
  6. Depression

Surgical History

The surgical history is a summary of the patient’s past surgeries. This includes information about the surgery, when it was done, and any complications that occurred.

Surgical History:

  1. Left hip replacement – 2012 due to fall with no complications

Social History

The social history is a summary of the patient’s social habits. This includes information about alcohol and drug use, smoking habits, and any other relevant information.

Social History: Mr. Smith lives at Happy Pines Nursing Home due to his aggressive behaviors and dementia diagnosis. He has a lot of support from his wife, daughter, son, and five grandchildren. Mr. Smith was previously a pilot before moving to Florida from New York. He has no known drug allergies and used to smoke half a pack of cigarettes a day for 45 years. He does not drink alcohol since he was admitted to the nursing home.

Family History

The family history is a summary of the patient’s family medical history. This includes information about any chronic conditions, hospitalizations, and any other relevant information.

Family History: Mr. Smith’s father passed away at the age of 70 from a heart attack. His mother passed away at the age of 75 from breast cancer. His sister is currently healthy and does not have any medical problems. His brother passed away at the age of 50 from a stroke. Mr. Smith has two healthy children and five healthy grandchildren.

Medications

The medications section is a summary of the patient’s current medications. This includes the medication name, dosage, and frequency.

Medications:

  1. Zyprexa 5mg – three times a day PRN
  2. Lorazepam 0.5mg – three times a day PRN
  3. Temazepam 30mg – once daily
  4. Ranitidine 150mg – twice daily
  5. Atorvastatin 40mg – once daily
  6. Lisinopril 20mg – once daily
  7. Metoprolol 25mg – twice daily
  8. tiotropium 18mcg powder – twice daily

Allergies

The allergies section is a summary of the patient’s known allergies. This includes the allergen and the reaction that occurred.

Allergies: NKDA

Review of Systems

The review of systems is a summary of the patient’s current symptoms. This includes information about any fatigue, appetite changes, weight changes, bowel or bladder changes, and any other relevant information.

 

Review of Systems/Physical Examination: T 102.8, HR 130, RR 22, and BP 220/110

Gen: pt unresponsive, lying in bed, having difficulty breathing

HEENT: eyes are closed but can be opened by the examiner, PERRLA noted. Mucus membranes dry, unable to assess the oropharynx as the patient is unable to hold the mouth open

CV: tachycardia, systolic murmur heart at the apex, no rubs or gallops heard

Pul: crackles heard at the bases of both lung fields, no coughing noted due to patient’s unresponsiveness

Abdm: bowel sounds are present in all fields, and the abdomen is soft and flat. Unable to assess tenderness secondary to patient’s altered mental status.

GU: pt arrived to ER in diapers, urine is clear and yellow

Extr: no edema noted, tremors were present in both upper and lower extremities

Msk: rigidity in bilateral upper extremities, Dantrolene administered and rigidity lessened within 45 minutes

Neuro: pt is unresponsive, and no longer withdraws to pain by either sternal rub or nail pressure

Skin: diaphoretic, hot to touch

Pertinent Diagnostic Tests

The pertinent diagnostic tests section is a summary of the patient’s current diagnostic tests. This includes information about any imaging studies, lab results, and any other relevant information.

Pertinent Diagnostic Tests: CT scan of the head showed no acute intracranial process. MRI of the brain showed no evidence of stroke. EEG was within normal limits.

Initial lab studies showed a creatinine level of 0.84, BUN of 12, and a GFR of >60. A urine dip and culture showed no evidence of infection. The CBC showed a WBC of 20.0 with 78% segmented neutrophils, 12% lymphocytes, and 0% monocytes. The chemistry panel showed a glucose level of 100, sodium level of 139, potassium level of 48, chloride level of 98, and CO₂ level of 23. The lipid panel showed a total cholesterol level of 211, LDL level of 130, HDL level of 50, and triglyceride level of 131. Sepsis labs are pending results.

assessment summary

Assessment and Plan

The assessment and plan section is a summary of the patient’s current condition and the plan for treatment. This includes information about any diagnoses, treatments, and any other relevant information.

Assessment: Mr. Smith is an 80-year-old male with a history of dementia, hearing loss, COPD, and hypertension who presents to the ER with shortness of breath, hypertension, rigidity, and a fever. He is currently febrile, tachycardic, and hypertensive. He has crackles at the bases of both lung fields and his abdomen is soft and flat. He has a systolic murmur heart at the apex, but no rubs or gallops are heard. Mr. Smith is unresponsive and has rigidity in his bilateral upper extremities. A CT scan of the head showed no acute intracranial process and an MRI of the brain showed no evidence of stroke. An EEG was within normal limits. Initial lab studies showed a creatinine level of 0.84, BUN of 12, and a GFR of >60. A urine dip and culture showed no evidence of infection. The CBC showed a WBC of 20.0 with 78% segmented neutrophils, 12% lymphocytes, and 0% monocytes. The chemistry panel showed a glucose level of 100, sodium level of 139, potassium level of 48, chloride level of 98, and CO₂ level of 23. The lipid panel showed a total cholesterol level of 211, LDL level of 130, HDL level of 50, and triglyceride level of 131. Sepsis labs are pending results.

Plan: Mr. Smith will be admitted to the hospital for further monitoring and treatment. He will be started on broad-spectrum antibiotics for his suspected sepsis. He will also be started on supplemental oxygen and IV fluids. Mr. Smith will be monitored closely for any changes in his condition and further diagnostic testing will be done as needed.

1. FEVER/COUGH/TREMOR/RIGIDITY

  • Dantrolene will be continued until a cause is identified
  • Neuroleptic medications have been held and agitation will be treated with benzodiazepines
  • Initial UA was negative
  • Fevers will be treated with Tylenol suppositories and ice packs
  • Continue routine labs including LFTs, CBC, Chemistries
  • Waiting for blood culture results and may consider sending sputum culture

2. DEMENTIA

  • All neuroleptic medications are being held and benzodiazepines orders entered for agitation treatment

3. HYPERTENSIVE CRISIS

  • Hydralazine PRN and Nicardipine were initiated to address hypertension. Patient responding to treatment.
  • Cardiovascular consult and intensivist consult initiated for medical management.

4. SEPSIS

  • Waiting for preliminary blood culture results
  • Broad spectrum antibiotics and fluid resuscitation initiated
  • Fever management

5. DISPOSITION

  • DNR initiated per family request

Conclusion

History and Physical of Admitted Patients is a very important part of the admitting and plan of care process. All relevant information must be included in this document so that the treating provider and healthcare team can make the best decisions for the patient.

What are your tips for interpreting an H&P? Let us know in the comments below!