Can you outline a complete focused history and physical (H&P) plan for the patient?

Focused History and Physical Examination Plan

For any patient presenting for evaluation, conduct a systematic assessment that prioritizes identifying the underlying cause, assessing severity, and determining functional impact through structured history-taking and targeted physical examination.

History of Present Illness

Begin by establishing the chief complaint and timeline of symptom development 1. Ask the open-ended question: "What is the main reason you are here and what would you like to accomplish from this visit?" 1. For each symptom reported:

• Onset, quality, intensity, distribution, duration, and course 2
• Exacerbating and relieving factors 2
• Progression since onset (better, worse, unchanged) 3
• Impact on daily activities and function 2

Critical: Obtain collateral history from family members or informants, particularly when cognitive impairment, behavioral changes, or loss of insight may be present 1. Informant reports provide added value beyond patient self-report alone 1.

Comprehensive Medical History

Document the following systematically 2:

1. Review of available medical records 2
2. Past medical history - emphasizing chronic conditions (diabetes, hypertension, heart disease, lung disease, renal disease, liver disease, malignancy, dementia, depression) 3, 4
3. Surgical history 2
4. Family history - obtain a 3-generation family history when assessing cardiomyopathy or inherited conditions 5; include premature coronary disease, stroke, diabetes, dyslipidemia 4
5. Social history:
   • Tobacco, alcohol, and illicit drug use (cocaine, amphetamines, methamphetamines) 4, 6, 7
   • Living environment and resources 2
   • Functional status and ability to perform activities of daily living 3, 2
   • Social support and relationships 2
6. Current medications - including dosages, over-the-counter drugs, herbal supplements, and nutritional supplements 6, 7
7. Medication history - substances that can raise blood pressure (licorice, nasal drops, oral contraceptives, NSAIDs, steroids, erythropoietin, cyclosporin) 4
8. Allergies 2
9. Review of systems 2

Functional Capacity Assessment

Determine the patient's ability to perform common daily tasks 6. This correlates with maximum oxygen uptake and provides prognostic information:

• Running or sports activities
• Walking up inclines (specify distance)
• Walking on flat surfaces (specify distance)
• Dressing without stopping to rest
• Standing tolerance (specify duration)
• Housework or shopping activities 3

Physical Examination

Vital Signs and General Appearance

Measure and document 4, 6, 5:

• Blood pressure in both arms 6
• Heart rate (pulse counting over at least 30 seconds, longer if arrhythmias present) 4
• Respiratory rate
• Temperature
• Weight and height with body mass index calculation 7
• Orthostatic blood pressure changes 7

Assess general appearance for cyanosis, pallor, dyspnea at rest or with minimal activity, Cheyne-Stokes respiration, nutritional status, obesity, skeletal deformities, tremor, anxiety 6.

Cardiovascular Examination

• Carotid pulse contour and bruits 6
• Jugular venous pressure and pulsations 6, 5
• Precordial palpation and auscultation 6
• Assessment for clinical congestion: jugular venous distention, orthopnea, bendopnea, leg edema 5
• Presence of implanted pacemaker or ICD 6

Respiratory Examination

• Auscultation of lungs 6
• Evidence of rales or pulmonary congestion 6

Abdominal Examination

• Palpation for organomegaly, masses, or enlarged kidneys 4, 6

Extremities

• Edema and vascular integrity 6
• Peripheral pulses 4

Neurological Examination

Conduct appropriately directed neurological assessment 2:

• Mental status and level of consciousness
• Cranial nerves
• Motor function (strength, tone)
• Sensory function
• Reflexes
• Gait assessment
• Coordination

Musculoskeletal Examination

Perform targeted musculoskeletal evaluation as indicated by presenting symptoms 2.

Condition-Specific Findings

For secondary hypertension or organ damage, look for 4:

• Cushing syndrome features
• Neurofibromatosis skin stigmata
• Enlarged kidneys on palpation

For heart failure, assess 3:

• Dyspnea at rest or with exertion
• Orthopnea (number of pillows used)
• Paroxysmal nocturnal dyspnea
• Recent weight changes
• Peripheral edema location and severity
• Fatigue and exercise intolerance

Psychosocial Evaluation

Document psychological and behavioral factors 2:

• Presence of anxiety, depression, or anger
• Psychiatric disorders
• Coping mechanisms
• Impact on mood and sleep
• Evidence of substance use or aberrant behavior
• Interpersonal relationships
• Family, vocational, or legal issues
• Patient expectations and goals 2

Documentation

Combine findings from history, physical examination, and any available diagnostic studies to create an individualized assessment and treatment plan 2. Document severity using standardized scales when appropriate 8.

Common Pitfall: Do not rely solely on patient self-report when cognitive impairment or behavioral changes are suspected—always seek collateral information from family or caregivers 1.