From the Guidelines
To create a comprehensive history and physical examination (H&P) document for your patient, you should follow a structured approach that includes chief complaint, history of present illness, past medical history, medications, allergies, family history, social history, review of systems, physical examination findings, assessment, and plan. When gathering information for the history component, it is essential to include demographic data, the patient's other pertinent health care providers, and the present status of visual function, as outlined in the refractive errors preferred practice pattern 1. The history of present illness should detail the patient's symptoms, their onset, duration, severity, and any exacerbating or alleviating factors.
Key components of the history include:
- Ocular symptoms such as eyelid swelling, diplopia, redness, photophobia
- Ocular history including prior eye diseases, injuries, surgery, or other treatments and medications
- Systemic history: medical conditions and previous surgery
- Medications: ophthalmic and systemic medications currently used, including nutritional supplements and other over-the-counter products
- Allergies or adverse reactions to medications
- Family history: pertinent familial ocular and systemic disease
- Social history, including occupation; tobacco, alcohol, illicit drug use; family and living situation as appropriate
The physical examination should be thorough and relevant to the presenting complaint, with vital signs and systematic examination of pertinent body systems, as suggested by the refractive errors preferred practice pattern 1. Documenting objective findings clearly, avoiding subjective interpretations, is crucial for both clinical decision-making and legal purposes. The assessment should include differential diagnoses based on the history and physical findings, and the plan should outline diagnostic tests, treatments, consultations, and follow-up recommendations. Given the importance of a well-documented H&P as both a clinical tool and a legal document, accuracy and completeness are essential 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
History and Physical Examination
To assist with your patient's history and physical (h and p), consider the following key points:
- A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations 2
- History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2
- Important communication skills for nurses when history taking include active listening, empathetic communication, and cultural sensitivity 2
Taking a Comprehensive Patient History
When taking a patient's history, consider the following steps:
- Prepare the environment for the patient interview 3
- Use effective communication skills, such as active listening and empathetic communication 2, 3
- Gather relevant information from the patient to inform diagnosis and treatment 2, 3
Importance of History and Physical in Diagnosis
The history and physical examination are crucial in diagnosis, as they:
- Provide a basis for selecting relevant diagnostic testing, leading to a timely and accurate diagnosis 4
- Protect patients from the risks of unnecessary testing and are cost-effective 4
- Have been the foundation of medical diagnosis for centuries, with a resurgence in refined form to improve diagnosis 5
Additional Considerations
While there is limited information on the specific patient's condition, consider the following general points: