M1 H&P: Introduction to Physical Examination

Devin Nickol, M.D.

I. Why even bother?

- At least ___ of all diagnoses can be made on the basis of history alone.     
- Over ___ of all diagnoses can be made by a combination of history and physical exam.

II. The format of an H&P

CC: Chief complaint -

HPI: History of present illness -

PMH: Past medical history -

Meds: Medications -

All: Allergies -

FH: Family history -

SH: Social history -

ROS: Review of systems -

PE: Physical exam -

Lab/XRay: Laboratory and XRay data -

Assessment:

Plan:

III: SOAP note format and sample note

Subjective:


Objective:


Assessment:


Plan:



IV: Classic components of physical examination
- Inspection:
- Auscultation:
- Palpation:
- Percussion:

- Other maneuvers:
V: Summary
- Despite technological advances, the vast majority of diagnoses can be made with _________ and __________________ alone.
- The physical exam has a defined role in both an ____ and a ____________.
- The ______ classic exam components can be used individually or combined to form additional exam techniques.