Taking a history and physical is med student 101. The first step is learning how to ask every possible question, then narrowing down the question pool with time and experience until only pertinent questions are asked when needed. However, it's important to be able to do a ridiculously thorough H&P for those mystery patients, or medicine rotations. This is my thought process for when I want to spend a lot of time with a patient to make sure I've covered everything.
The HPI is where you get the patient's current health story. Why is the patient here in the office/ED/hospital? A good HPI will help you narrow down the rest of your H&P so you're not in the room forever.
Chief complaint: I'm an informal guy, so I like to start informally. I introduce myself, then say "What's going on?" or "What brings you in?" I also like to ask "What can I help you with today?" because hopefully this goes straight to why the patient is here. Often the chief complaint listed in the EMR or chart is not why the patient is there, and that can distract from the purpose of their visit. I try to use this question to direct where I go for the rest of the visit.
Duration/Timing/Pain Quality: Once they tell me about the symptom(s) bothering them, I try to get a general sense of what's going on. I want to know how long they've had the problem, and whether it's constant or coming/going. If it's pain, describe the pain, getting the patient to use their own words. Importantly, I try to get them to compare it to something. Is their stomach pain like a muscle cramp, or does it feel like gas pains? This helps me narrow my differential.
Location: After getting the timing and quality, I go for location. Where is the problem, has it been there the whole time, or has it moved around? If they say "it's all over," I ask them to point with one finger at the worst location.
Alleviating/Aggravating: Now I go for what makes it better (alleviating) and worse (aggravating). Is it different with movement, with eating, or with sleeping? Have they had any recent changes in their daily routine or habits? Sometimes with a little prodding, a patient may recall that they went to a new restaurant, or started a new drug or workout routine...just around the time the symptoms started.
Pain Severity: If the patient is having pain, you're supposed to ask how severe it is. I'm not a huge fan of the 1-10 pain scale, but the benefit is that you can determine whether the pain improves or worsens over time.
Focused ROS: Once I've obtained a picture of the symptoms, I try to do a focused ROS to help me with my differential. What associated symptoms does the patient have? I always get caught up in asking about symptoms that confirm the most likely diagnosis, but remember to ask questions related to other diagnoses on your differential, as negative symptoms are extremely important as well.
Qualifying questions: Every once in a while, I get a vague or confusing history, and I'm not always sure what the goal of the interview is. Sometimes I'll ask the patient, "what is your main concern today?" If that doesn't work, I really like the approach of "if we can only do one thing with this visit, what do you want to do?" Often that will help direct the rest of the visit if they have multiple medical issues.
Summarize: Once I have as much information as I need, I try to summarize the highlights. I usually just say "I want to make sure I hit all the important points," then I give a brief summary back to the patient to confirm. Often they'll catch a small but relevant detail that I missed.
Further details: Next I'll ask if there is anything either IMPORTANT or RELEVANT that I did not already ask them about. I like this, because it's open ended and a patient can include anything on their mind that you didn't already ask about. Usually they'll say nothing, but you never know what they'll mention.
Questions? Last, I ask if what questions they have. This may also catch some things that you didn't cover in your questions. If they have someone else in the room with them, I'll ask them if they have questions too. Sometimes I do this at the end of the HPI, other times I do it after completing the rest of the history and physical.
Now I want to get a picture of their health up until this point. Let's break it down.
Past Medical History: I want to know a thorough list of the patient's medical conditions. If they remember them all, great! If they don't, try to find a list in the chart and review it to see if there's anything else that needs to be added. If they don't know their medical history, I always check if they have a history of: Hypertension, Diabetes, Myocardial Infarction, Stroke, COPD, and Cancer. This is also a good place to ask about any major illnesses or injuries, as well as prior hospital admissions.
Medications: Now I want to know all of their medications, including dosages and timings. If they bring in their bottles I go through each one to confirm that they take it and that it's not just old. I'll also try going through the chart and removing old medications they don't take anymore. Pro tip: if I have time, I will go through and match up the medical history with the medications, to confirm that each disease is being treated, and each medication has a disease it's treating.
Past Surgical History: Here you want to include any procedure that has required an operating room setting, either with local or general anesthesia. This is useful for diagnosis (hard to have gallstones if the gallbladder has been removed) as well as planning future surgeries. I don't usually count getting stitches, or neonatal circumcision, but you can if you really want (but actually, don't).
Allergies: Want to look like a champ? Ask the patient what reaction they have to each medication. If a drug causes itching or a rash, it can still be used. Causing anaphylaxis is a whole different story. I had a patient once tell me she was allergic to broccoli...because it gives her gas.
Psychiatric History: Sometimes patients don't think of these as medical conditions, so they don't bring them up during the medical history portion. Ask about a diagnosis of depression, anxiety, bipolar, or schizophrenia. Ask what medication the patient takes, and who prescribes it. If you're concerned, ask about suicidal or homicidal ideations.
Parents: If you're not sure about the parents' health or living/dead status, an open ended "tell me about your parents' health" always works. Get an idea of any possible hereditary diseases, and if they are deceased, at what age did they die.
Siblings: Find out the health status of siblings, and relative ages and age at death. Again, listen for possible hereditary conditions.
Children: Ask how many children, and how old. Always a good opportunity to get to know the patient better by asking about the kids, school, that sort of thing. Find out if the kids are healthy. Sick kids are a major stressor on the parents and can affect their health.
Extended Family History: I ask about the three generations but not the spouse, as they aren't related. I then try to get an extended family history, asking the same questions as in the PMHx: Hypertension, Diabetes, Myocardial Infarction, Stroke, COPD, and Cancer. I also ask about any known hereditary conditions, or any relevant conditions to the chief complaint for the visit, if concerned.
Diet/Exercise/Sleep:For diet, I want to know how often the patient eats out, and whether they eat enough fruits and vegetables. Unless I'm specifically discussing losing weight, that's all I really need to know to determine whether they eat healthy. For exercise, I just ask what they do for exercise (not IF they exercise). Then for sleep, I ask what time they go to bed and when they wake up, and if they feel like they're well rested. If the patient seems to have sleep difficulties I'll offer tips for sleep hygiene at the end of the interview.
Smoking: Most people today don't smoke, so I always start by asking if they smoke. If yes, I ask how much on average per day/week, and for how many years. You want to be able to calculate the pack-years. If they've quit, I give them a high-five (same for if they're losing weight). If they do smoke, I like to say "if you ever change your mind about quitting, we're always here to help" and leave it at that.
Drinking: You can either ask the patient if they drink, or how much they drink. There's no right answer and I've gotten called out for asking one when the attending preferred the other. It's important to ask what the patient drinks, how much, and how often. I had a patient who drank "two beers," but the beers were 10% alcohol and were in 24oz cans, AKA 8+ beers a night.
Drugs: This is just a yes/no section, I ask about marijuana, cocaine, heroin, and narcotics, and leave it at that.
Sexual Activity: Everyone's favorite section! I start by asking if the patient is sexually active, then with men, women, or both. Finally I ask about what sort of protection the patient uses. Remember, if she had her tubes tied, she probably doesn't use protection anymore (I asked this once and the patient laughed). I don't usually discuss STIs or anything else unless the patient brings it up. If they don't use protection, I try to offer advice or counseling if they appear interested.
Support/Stressors: After talking about sex, I try to de-escalate the conversation. I ask who the patient talks to for support, and what sort of stressors they might need support for.
Safety: Along these lines, I ask who the patient currently lives with. Is the patient concerned about anyone threatening or hurting them? This is better than asking if they feel safe in their home, because the joke is that patients will say "yeah, I don't wear socks on my newly waxed floors." You might also consider asking about a history of physical, verbal, or emotional abuse, if concerned.
Occupation: Last, I ask whether the patient is currently employed and what they do for work. Often I try to squeeze this in earlier in the interview, because it's a good chance to build rapport with the patient. This is also relevant if you're concerned about occupational exposures.
The review of systems can offer a lot of useful information. Most times it doesn't, but it can! Sometimes a patient will mention a concerning symptom that they don't realize the severity of, or they might mention something that completely changes the differential. Therefore, if you're short on time, try to ask some general questions and some questions relevant to your differential, to see if anything changes.
Constitutional: Ask about fevers, chills, loss of energy, unexpected weight gain/loss, changes in appetite, heat/cold intolerance, night sweats.
HEENT: Ask about headaches, blurry vision, changes in vision, double vision (diplopia), use of glasses/contacts, ringing in the ears (tinnitus), vertigo, loss of hearing, pain in the ears, runny nose (rhinorrhea), bloody nose (epistaxis), sinus pain, bleeding gums, loose/chipped teeth, pain in the mouth, sore neck, sore throat, enlarged lymph nodes, anterior neck swelling/pain (goiter/thyroiditis).
Pulmonary: Ask about (bloody) cough, wheezing, sputum production, pain with breathing (dyspnea), lightheadedness.
Cardiac: Ask about chest pain, palpitations, edema, blue discoloration in the fingers/toes/lips (cyanosis), changes in exercise tolerance.
Gastrointestinal: Ask about nausea, vomiting, bloody vomit (hematemesis), difficulty swallowing (dysphagia), painful swallowing (odynophagia), heartburn/reflux, indigestion/bloating, diarrhea, constipation, dark stools (melena), blood in the stools (hematochezia) yellow skin/eye coloration (jaundice), hemorrhoids, hernias.
Genitourinary: Ask about pain/burning with urination (dysuria), frequency, urgency, blood in the urine (hematuria), getting up frequently at night to urinate (nocturia), incontinence, erectile dysfunction.
Musculoskeletal: Ask about joint pain in all the extremities, neck, and back, arthritis, broken bones.
Neurologic: Ask about numbness, pain, and tingling in all the limbs, seizures, strokes, migraines, syncope, changes in gait, difficulty remembering.
Psychiatric: Ask about difficulties concentrating, trouble completing everyday tasks, abnormal changes in emotions, seeing/hearing things other people can't.
Integumentary: Ask about rashes, itching (pruritus), changes in moles, sores, ulcers, dryness.
Hematologic: Ask about increased bleeding, petechiae, frequent infections, pale skin, enlarged lymph nodes.
Breast: Ask about lumps, pain, nipple discharge.
This is the objective part of the exam. Your goal is to observe the patient and look for abnormalities, along with percussion, palpation, and auscultation. Think about your differential, and how physical exam findings might alter your list of diagnoses.
General: Examine the patient's "general appearance," how sick do they look? Do they look well put-together, or are they disheveled? Use "well-nourished" to describe any patient that has a BMI in the healthy range or higher. You may also mention that they are alert and oriented here.
Vital Signs: If not already obtained, check heart/respiratory rate and blood pressure
Skin: Examine the skin for any dryness, rashes, sores, scars, or moles. Check for discoloration (anemia/jaundice/cyanosis/ecchymosis). Usually this isn't relevant unless you're specifically looking for something, or something that's really obvious stands out. Don't go counting the moles on every patient's back. If you find a rash or lesions, make sure to describe it as specifically as possible, even if you don't know the correct terminology. Record the size, location, shape, coloration, and whether it is palpable.
HEENT: If we leave all the cranial nerve exam parts for the neuro exam, you should focus on the ears, nose, and throat. Check the ears, looking for the gray pearly tympanic membrane (finding the cone of light should help. For better viewing, pull the ear upwards and outwards, hold the otoscope like a pencil in the same hand as the ear (ie left hand for left ear), rest your 5th finger on the cheekbone, and get a nice close look inside the ear. Examine the nose for any inner growths or bleeding. Check the mouth for sores, weird teeth, and enlarged tonsils. Palpate the head and neck for enlarged lymph nodes, note if they are mobile or painful. Also examine the thyroid by having the patient swallow while observing, palpating the isthmus, and palpating the lobes from behind. Also make sure then head is not abnormally shaped. Although part of the eye exam will be covered in neuro, mention whether there is lid drooping (ptosis) or eye bulging (proptosis), or if the eyes have abnormal coloration. If available, perform a fundoscopic exam to look for retinal abnormalities.
Pulmonary: Check to see if there are any abnormalities in chest wall shape/symmetry. Take a feel of the chest wall, is there any pain on palpation? Next, percuss the posterior wall to listen for hyperresonance (seen in pneumothorax) or dullness to percussion (seen in pleural effusion and pneumonia). Listen to at least one breath in 4-6 areas of the posterior chest, listening to the right and left sides consecutively for comparison. Have the patient breath in and out with their mouth for best sound, not through the nose. Listen for increased breath sounds (pneumonia) or decreased breath sounds (pneumothorax and pleural effusion). You should also listen to the apices on the anterior chest, and listen laterally as well. If you want to be a pro, do tactile fremitus and egophony, but these are not used frequently.
Cardiac: Check carotid, radial, dorsalis pedis, and posterior tibial pulses (can also be done with extremities). You don't really need to check brachial, axillary, or femoral unless you can't obtain distal pulses. Listen to the four auscultory areas of the heart: aortic, pulmonic, tricupsid, and mitral. Palpate the PMI, best felt at the 5th intercostal space and the mid-clavicular line while the patient lies on their left side (left lateral decubitus position). Also palpate for a thrill or heave. The pro move in the cardiac exam is looking for the jugular venous pressure. Do this by placing the head of the bed at 30 degrees, having the patient look to the left, and looking for a faint pulsation above the right clavicle (shining a light obliquely helps). Abnormal JVP (AKA JV distension AKA JVD) is seen when the pulse is 5-6cm above the sternal angle. Increased pulsation usually indicates a backup of flow, as seen in right-sided heart failure.
Abdomen: Look for abdominal scars from previous surgeries. You should listen to bowel sounds first, before pushing on the abdomen makes them change. Technically these are nonspecific findings, but report what you hear. Next, percuss the four quadrants for a tympanic abdomen (indicating air or fluid). Next, palpate each quadrant lightly and deeply to look for masses or tenderness. Palpate for the liver edge on the right side, the splenic edge on the left side, and the bladder in the suprapubic region (these are usually nonpalpable in a normal patient). You can percuss for the liver span by tapping on the abdomen while listening with the stethoscope, the tapping should sound different over the liver. You can also palpate the abdominal aorta by pressing down into the abdomen at midline as the patient exhales. Listen for renal artery bruits by listening with the bell of the stethoscope lateral to midline, inferior to the umbilicus.
Extremities: Check fingers for slow capillary refill. Nails may be excessively rounded (clubbing), pitted (psoriasis), or concave (iron deficiency). Look for abnormalities in the joints, such as swelling, crackling/popping with movement (crepitus), redness (erythema). Test the patient's active range-of-motion (ROM), then test passive ROM (AKA have patient move joint, then move while patient is relaxed).
Neurologic: So important, it gets its own page!
You've taken a full history and performed the entire physical exam. I like to wrap up by summarizing any pertinent positives without going into too much detail/depth. I then ask what questions the patient might have, and whether there is anything important we haven't discussed. At this point, I'm ready to leave the room and write up my note or present to my team.