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Comprehensive Adult History and Physical . (Sample Summative H&P by M2 Student) t, it best exemplifies the documentation skills students are expected and able to acquire by the end of . For additional H&P samples go to P-2 Webcourses home page and click on the COP/Portfolio Resources page.
History of Present Illness. This is the first admission for this 56 year old woman, who states she was in her usual state of good health until one week prior to admission. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest pain which she describes as dull and aching in character.
Surgical history with dates, indications and types of operations. OB/Gyn history with obstetric history (G,P – number of pregnancies, number of live births, number of living children), menstrual history, birth control. Psychiatric history with dates, diagnoses, hospitalizations and treatments.
VITALS. Temperature: 37.5° C oral (list the site where the temperature was taken, i.e., oral, rectal, tympanic membrane, axillary) Blood Pressure: R Arm/Palpation (Systolic) - 120. R Arm/Auscultation- 126/70. L Arm/Palpation (Systolic) - 122. L Arm/Auscultation- 126/70 (Document if you need to use a large cuff or thigh cuff for an obese arm ...
History and Physical Examination (H&P) Examples. The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples. H&P 1. “77 yo woman – swelling of tongue and difficulty breathing and swallowing” H&P 2.
History of Present Illness: Ms J. K. is an 83 year old retired nurse with a long history of hypertension that was previously well controlled on diuretic therapy. She was first admitted to CPMC in 1995 when she presented with a complaint of intermittent midsternal chest pain.
Sample Pediatric History and Physical Exam. Date and Time of H&P: 9/6/16, 15:00. Historian: The history was obtained from both the patient’s mother and grandmother, who are both considered to be reliable historians. Chief complaint: "The rash in his diaper area is getting worse."
