How do I perform a systematic admission history and physical examination?

Systematic Admission History and Physical Examination

A comprehensive admission history and physical examination should systematically cover patient demographics, chief complaint, history of present illness, past medical/surgical history, medications, allergies, family history, social history, review of systems, vital signs, and a complete physical examination with particular attention to systems relevant to the presenting complaint. 1, 2, 3

Core Components of Admission History

Essential Historical Elements

Patient Identification and Demographics

• Document date and time of admission
• Patient age, race/ethnicity (relevant for disease risk stratification)
• Reason for admission and admitting service 2, 3

Chief Complaint and History of Present Illness

• Time of symptom onset or when patient was last normal 4
• Initial symptoms and their progression 4
• Chronology, quality, intensity, distribution, duration, and course of symptoms 1
• Exacerbating and relieving factors
• Associated symptoms (motor, sensory, autonomic changes) 1

Past Medical History - Systematically Document:

• Cardiovascular: hypertension, coronary disease, heart failure, arrhythmias 5, 3
• Pulmonary: asthma, COPD, chronic bronchitis requiring treatment 5
• Endocrine: diabetes mellitus, thyroid disease 4, 2
• Renal: chronic kidney disease, dialysis history 5
• Neurological: stroke, dementia, seizures 5, 4
• Psychiatric: depression, anxiety requiring treatment 5
• Hepatic: chronic hepatitis, cirrhosis 5
• Malignancy: type and date of diagnosis 5
• Autoimmune: lupus, rheumatoid arthritis, scleroderma 5

Surgical History

• All prior surgeries with dates
• Complications from previous procedures
• Anesthetic complications 6

Medications

• Current medications with doses and frequencies
• Recent medication changes
• Anticoagulants and antiplatelet agents (critical for bleeding risk) 4
• Corticosteroids (topical, oral, inhaled, injected) 7, 8
• Over-the-counter medications and supplements 2
• Medication adherence and barriers 3

Allergies

• Document specific allergens and type of reaction 1, 6

Family History

• Cardiovascular disease, sudden death 8, 9
• Diabetes, hypertension, hyperlipidemia 4
• Malignancy
• Hereditary conditions relevant to presentation 7, 8

Social History - Critical Elements:

• Smoking: current status, pack-years 4
• Alcohol: quantity, frequency, history of withdrawal 3
• Illicit drug use: type, route, frequency (particularly cocaine and sympathomimetics for cardiovascular/neurological presentations) 4, 2
• Occupational exposures and status 1
• Living situation and functional status 3
• Sexual history when relevant (number of partners, types of sexual contact, barrier use) 2

Review of Systems Must be comprehensive but focused on high-yield systems:

• Constitutional: fever, weight changes, fatigue 5
• Cardiovascular: chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitations 5, 3
• Respiratory: dyspnea at rest and on exertion, cough, wheezing 5
• Neurological: headache, weakness, sensory changes, seizures 4
• Gastrointestinal: nausea, vomiting, abdominal pain, bowel changes 5

Physical Examination - Systematic Approach

Vital Signs (Document All)

• Blood pressure (both arms if cardiovascular concern, orthostatic measurements) 4, 3
• Heart rate and rhythm
• Respiratory rate
• Temperature
• Oxygen saturation
• Weight and height with BMI calculation 10, 3
• Pain score 1

General Appearance

• Level of consciousness (Glasgow Coma Scale for neurological presentations) 4
• Apparent distress
• Nutritional status
• Body habitus 10

Head, Eyes, Ears, Nose, Throat

• Pupillary examination (size, reactivity, symmetry) 4, 7
• Fundoscopic examination when indicated 7, 8
• Oral mucosa, dentition
• Thyroid examination

Cardiovascular Examination

• Jugular venous pressure and waveforms 5, 3
• Carotid pulses (quality, bruits)
• Precordial inspection and palpation (heaves, thrills, point of maximal impulse)
• Auscultation: heart sounds, murmurs, rubs, gallops (S3, S4) 5
• Peripheral pulses (radial, femoral, dorsalis pedis, posterior tibial)
• Peripheral edema: location, severity, pitting vs non-pitting 5

Respiratory Examination

• Inspection: respiratory pattern, use of accessory muscles
• Percussion
• Auscultation: breath sounds, crackles, wheezes, rhonchi 5, 4

Abdominal Examination

• Inspection: distension, surgical scars
• Auscultation: bowel sounds
• Palpation: tenderness, masses, organomegaly (hepatomegaly, splenomegaly)
• Percussion: ascites 5, 4

Neurological Examination

• Mental status: orientation, attention, memory
• Cranial nerves (all 12 when neurological presentation)
• Motor: strength (graded 0-5), tone, bulk
• Sensory: light touch, pain, proprioception, vibration
• Reflexes: deep tendon reflexes, pathological reflexes (Babinski)
• Coordination and gait
• Use standardized scales: NIH Stroke Scale for stroke presentations 4, focused neurological exam for other presentations 9

Musculoskeletal Examination

• Joint examination: swelling, erythema, range of motion, tenderness 5, 1
• Spine examination when indicated
• Gait assessment 1

Skin Examination

• Rashes, lesions, ulcers
• Signs of chronic disease (jaundice, pallor, cyanosis)
• Pressure injuries in immobile patients

Psychiatric Assessment

• Mood and affect
• Thought process and content
• Screen for depression and anxiety using direct questions 2
• Assess for suicidal or homicidal ideation when indicated

Critical Documentation Standards

Common Pitfalls to Avoid:

• Incomplete vital signs documentation (particularly orthostatic measurements when relevant) 11
• Missing weight documentation 11
• Inadequate chaperone documentation for sensitive examinations 11
• Failure to document time of symptom onset (critical for time-sensitive interventions) 4
• Incomplete medication reconciliation, especially anticoagulants 4
• Missing substance use history 2, 3

Quality Improvement Measures: Studies demonstrate that standardized documentation improves completeness from 64% to 80% for physical examinations 11 and significantly improves student evaluations when systematic approaches are implemented 12. Use structured templates or checklists to ensure completeness 13, 12.

Initial Laboratory and Diagnostic Studies

While not part of history and physical per se, the initial workup should be guided by findings:

• Complete blood count
• Comprehensive metabolic panel (electrolytes, renal function, glucose, liver enzymes)
• Coagulation studies when indicated 4
• Cardiac biomarkers for cardiovascular presentations 4
• Urinalysis 4
• ECG 4
• Imaging as clinically indicated 4, 3

The history and physical examination must be completed within 24 hours of admission 11 and should directly inform the diagnostic and therapeutic plan, with particular attention to identifying time-sensitive conditions requiring urgent intervention 4.