The History and Physical Exam, often called the "H&P" is
the starting point of the patient's "story" as to why they sought
medical attention or are now receiving medical attention.
|
The History portion contains the chronology of what
is wrong with the patient - often the "what is wrong
with the patient" is called the "chief complaint" and
is often abbreviated "CC" in the History documentation
in the medical record. For example, a patient may report
that there is blood in her sputum and this has been
present for a period of one week. The physician will
often write: CC: "Patient reports blood in sputum for
a period of one week."
Following the chief complaint, the physician will
|
also document any other pertinent History about the patient's
medical, behavioral, and psycho-social aspects.
Following the History, the physician SHOULD then perform
a Physical Exam (or "PE"). The Physical Exam includes both
objective and subjective assessments of the patient's physical
being. Documentation of the Physical Exam is typically grouped
by body system, such as Head, Eyes, Ears, Nose and Throat
(often abbreviated "HEENT"), Respiratory, Genito-Urinary,
etc. Objective medical measurements such as blood pressure,
pulse rate, temperature, etc. are made and documented. There
are also many subjective measurements made during the PE,
such as visual observation and palpation, often with "best
judgment" assessments as to size, location, and involvement
of any abnormal finding.
COMMON PHYSICAL EXAM PROCEDURES
Key information (information to look for and pay attention
to and to document with regard to collecting pertinent information
about the patient's cancer): obvious lesions; palpable mass(es);
ulceration; size (in centimeters or inches) and location (especially
if tumor crosses midline) of primary tumor(s); swelling or enlargement
of any masses or organs (organomegaly, hepatomegaly, splenomegaly,
hepatosplenomegaly/HSM); fixation of mass; invasion/erosion
of bone; laterality, size and number of palpable lymph nodes,
especially cervical, supraclavicular, axillary or inguinal;
evaluation of cranial nerves; evidence of "frozen" pelvis. For
lymphoma, involvement of lymph nodes (matted nodes, fixed vs.
mobile, lymphadenopathy, enlarged, "shotty" nodes, palpable,
enlarged, visible swelling). For central nervous system tumors,
neurologic examination for signs and symptoms (which help identify
the location of the tumor); vision changes; attention deficit;
focal deficit (blindness, taste aberrations); tumor impingement
on a specific nerve or structure; mass effect (light-headedness,
loss of vision); evidence of increased intracranial pressure
(edema, headache, nausea and vomiting); evidence of obstructive
hydrocephalus.
DIGITAL RECTAL EXAMINATION
manual or digital examination of the lower portion of the
rectum, perineum and surrounding tissues using a gloved finger
inserted into the anus. During the examination, the examining
finger can feel the prostate gland. Also called DRE, rectal
exam, manual exam.
Key words/possible involvement: nodularity, palpable
tumor, induration, fixation of seminal vesicles, enlargement,
firmness, lesion, fixation to surrounding tissues, neoplasm,
malignancy, active bleeding.
Other words/no involvement: if there is no mention
of prostatic abnormality during the exam; benign prostatic
hypertrophy.
EXAMINATION OF ABDOMEN
Key information: masses and enlarged organs (organomegaly;
hepatomegaly; splenomegaly); palpable lymph nodes; jaundice
(yellowing of skin and eyes due to blockage of bile ducts).
PELVIC EXAMINATION
manual or speculum evaluation of cervix, vagina, rectum, external
genitalia. Digital examination of the rectum and vagina is
also called a rectovaginal exam.
VISUAL EXAMINATION
(also called indirect or mirror examination) visualization
of clinically accessible areas of the head and neck by viewing
them in a mirror or through an endoscope (see also Endoscopies).
VISUAL FIELD EXAMINATION
a test to determine any defects in the patient's vision, which
in turn may reveal the location of a brain tumor. Visual field
alterations caused by problems in different brain sites are
unique.
|