Elements of a History and Physical

ID/CC
HPI

PMH

Birth hx: mom age, G/P, OB labs (GBS, HSV, STIs), prenatal care/complications, ROM duration, GA/mode/APGARs, delivery complications, birth wt, length of hosp stay, neonatal problems
Hosp
Surg
Meds
Allergies
Immunizations
Diet: br feed vs. formula (type), amount, freq
Growth/development: physical growth, social/emotional, motor, language/cognitive

FHx

Birth defects/Genetic
Asthma/allergies
Sudden death/CHD
Bleeding d/o
Childhood cancer
Developmental delays
Emotional/behavioral problems
Other significant illnesses

SHx

Lives w/ (parents, siblings)
Childcare/school
Sick contacts
Parents’ profession
Stressors at home
Smokers, firearms, seatbelts, car seats
Travel hx, pets
Friends
Activities/interests

ROS

Gen: fever, wt loss/gain, activity
HEENT: eye pain, vision loss, drainage, otalgia, hearing loss, otorrhea, rhinorrhea, epistaxis, dentalgia, sore throat, hoarseness
Resp: cough, wheeze, stridor, apnea, cyanosis, resp difficulty, retractions, flaring
CV: murmur, CP
GI: feeding/appetite, N/V, diarrhea/constipation, abd pain, hematochezia/melena
GU: freq/UO, dysuria, hematuria, d/c
Neuro: sz, LOC, numbness, weakness
M/S: joint swelling, tenderness, weakness
Skin: rashes, lesions
Endo: polyuria/dipsia
Heme/Lymph: bleeding, anemia, jaundice, swollen glands
Psych: mood, sleep problems

PE

Vitals: Temp HR RR BP O2sat Wt Ht BMI (with percentiles)
Gen: alertness, distress, body habitus, position
HEENT: NCAT, fontanelles; PERRLA, sclera, conjunctiva; nares, nasal mucosa; MM hydration, cyanosis, dentition, post pharynx
Neck: rigidity, thyroid, LNs, carotids
Chest: retractions, wheeze, crackle, stridor, focal decrease BS, I/E ratio, percussion
CV: RRR, m/r/g, distal pulses, cap refill
Abd: ND, normoactive BS, soft & NT, HSM, masses
GU: Tanner stage, circ, testicle descend, anus
Skin: rashes, lesions
Neuro: CN II-XII, sensation, DTRs, tone/bulk, strength, gait, cerebellar fxn
M/S: joints (swelling, warmth, tenderness), A&P ROM

Labs/Diagnostics

A/P (What Why -H&P, labs DDx W/U Tx)

FEN/GI
Resp
CV
ID
Renal/GU
Heme/Lymph
Neuro/Pain
MS/Rheum
Endo
Skin
Psych
Prophylaxis/Adv direct
D/c planning