Can you provide a template for dictating a history and physical (H&P) for an infectious disease evaluation?

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Last updated: October 15, 2026 • View editorial policy

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History and Physical Template for Infectious Disease Evaluation

For infectious disease consultations, structure your H&P to systematically capture exposure history, immune status, and infection-specific clinical features while documenting elements that guide antimicrobial stewardship and prognostic assessment.

Chief Complaint and History of Present Illness

Document the following systematically:

  • Symptom onset and timeline: Exact dates of symptom onset, fever patterns (continuous vs intermittent), and progression

  • Fever characteristics: Maximum temperature, timing, associated rigors or night sweats

  • Localizing symptoms:

    • Respiratory: cough (productive vs dry), sputum character, dyspnea, pleuritic pain
    • Genitourinary: dysuria, frequency, flank pain, discharge
    • Gastrointestinal: diarrhea (bloody vs watery), abdominal pain, nausea/vomiting
    • Neurologic: headache, altered mental status, focal deficits, photophobia
    • Skin/soft tissue: rash distribution and character, wound characteristics, pain out of proportion

  • Severity indicators: Confusion, hypotension, tachypnea >20/min, tachycardia >90/min, temperature >38°C or <36°C 1

Infectious Disease-Specific History

Exposure and Epidemiologic Risk Factors

Travel history 2:

  • Countries/regions visited with specific dates
  • Dates of symptom onset relative to travel
  • Malaria prophylaxis use and adherence
  • Freshwater exposure, animal contacts, insect bites
  • Food and water sources

Occupational/environmental exposures 3, 4:

  • Farming, animal handling (specify species)
  • Bird exposure (type, duration, intensity)
  • Water damage, mold, air conditioning systems
  • Healthcare work, laboratory exposure
  • Homeless shelter, correctional facility

Sexual and substance use history 5:

  • Number and gender of partners
  • Condom use patterns
  • Receptive oral, vaginal, or anal intercourse
  • Injection drug use: needle sharing, last use
  • Genitourinary symptoms or discharge
  • Partner STD history

Contact history:

  • Sick contacts with similar symptoms
  • Household members with infections
  • Recent hospitalization or healthcare facility exposure
  • Tuberculosis exposure and prior TST results 5

Past Medical History - Infection Risk Stratification

Immunocompromising conditions 5:

  • HIV status: CD4 count (current and nadir), viral load, ART regimen and adherence
  • Solid organ or hematopoietic stem cell transplant
  • Active malignancy or chemotherapy
  • Immunosuppressive medications (corticosteroids, biologics, DMARDs)
  • Diabetes mellitus, chronic liver disease, chronic kidney disease
  • Asplenia (functional or anatomic)

Chronic conditions affecting infection risk 1, 3:

  • COPD, bronchiectasis
  • Cardiovascular disease
  • Neurologic disease with aspiration risk
  • Peripheral vascular disease, neuropathy
  • Chronic wounds or ulcers

Prior infections 5:

  • Previous opportunistic infections with dates
  • Recurrent infections (UTI, pneumonia, cellulitis)
  • Prior positive cultures and resistance patterns
  • History of C. difficile infection
  • Latent TB infection and treatment

Antibiotic and Medication History

  • Current and recent antibiotics (within 3 months): specific agents, doses, duration, response 1
  • Antiretroviral therapy: regimen, adherence, prior regimens, resistance testing results 5
  • Immunosuppressive medications: doses and duration
  • Prophylactic antimicrobials: PCP, MAC, fungal prophylaxis
  • Drug allergies: specific reactions (distinguish true allergy from intolerance) 5
  • Over-the-counter and herbal supplements: potential drug interactions 5

Vaccination History 5

  • Pneumococcal (PCV13, PPSV23)
  • Influenza (current season)
  • Hepatitis A and B
  • Tetanus/diphtheria
  • COVID-19
  • Others relevant to travel or exposure

Social History 5

  • Living situation: alone, group home, nursing facility
  • Tobacco use (pack-years)
  • Alcohol use (quantify)
  • Recreational drug use
  • Recent incarceration
  • Homelessness
  • Pets and animal exposures

Physical Examination

Vital Signs and General Appearance

  • Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
  • Appearance: toxic vs well-appearing, distress level
  • Mental status: alert, confused, lethargic

Systematic Examination for Infection

Skin and lymph nodes:

  • Rash: distribution (diffuse, localized), morphology (macular, papular, vesicular, petechial)
  • Eschars or ulcers
  • Injection sites or track marks
  • Lymphadenopathy: location, size, tenderness, fluctuance
  • Jaundice

Head and neck:

  • Oral lesions: thrush, ulcers, Kaposi sarcoma
  • Pharyngeal erythema or exudate
  • Sinus tenderness
  • Nuchal rigidity

Cardiovascular:

  • New murmur (endocarditis)
  • Peripheral stigmata of endocarditis (Osler nodes, Janeway lesions, splinter hemorrhages)

Pulmonary:

  • Crackles, wheezes, bronchial breath sounds
  • Dullness to percussion (effusion)
  • Egophony

Abdominal:

  • Hepatosplenomegaly
  • Right upper quadrant tenderness
  • Peritoneal signs
  • Costovertebral angle tenderness

Genitourinary:

  • Genital lesions or discharge
  • Testicular or prostatic tenderness

Musculoskeletal:

  • Joint effusion, erythema, warmth, range of motion
  • Vertebral tenderness
  • Extremity edema or erythema

Neurologic:

  • Focal deficits
  • Cranial nerve abnormalities
  • Meningeal signs

Assessment and Severity Stratification

Document Infection Severity Classification

For diabetic foot infections 1:

  • Grade 1: Uninfected
  • Grade 2: Mild (erythema 0.5-2 cm, skin/subcutaneous only)
  • Grade 3: Moderate (erythema >2 cm or deeper structures, no SIRS)
  • Grade 4: Severe (SIRS present: temp >38°C or <36°C, HR >90, RR >20, WBC >12,000 or <4,000)

For pneumonia 3, 6:

  • Risk factors requiring hospitalization: age >65, altered mental status, respiratory rate >30, hypotension, multilobar involvement

Differential Diagnosis

List in order of likelihood based on:

  • Clinical syndrome
  • Exposure history
  • Host factors
  • Local epidemiology

Plan

Diagnostic Studies Ordered

  • Cultures (blood, urine, respiratory, wound) with timing relative to antibiotics
  • Imaging with specific indication
  • Serologies or molecular testing
  • Invasive procedures planned

Antimicrobial Therapy

  • Empiric regimen with rationale
  • Planned duration
  • Stewardship considerations (de-escalation plan, biomarkers for stopping)

Infection Control Precautions

  • Isolation type if indicated
  • Public health notification requirements

Follow-up and Monitoring

  • Clinical response parameters
  • Laboratory monitoring
  • Repeat imaging timing

Key Documentation Pitfalls to Avoid:

  • Failing to document exact travel dates and locations for febrile returned travelers 2
  • Not specifying CD4 count and viral load in HIV patients 5
  • Omitting antibiotic exposure within past 3 months when assessing resistance risk 1, 3
  • Inadequate sexual history limiting STD screening appropriateness 5
  • Missing SIRS criteria documentation that determines infection severity 1

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.