History and Physical (H&P): Your Most Powerful Medical Tool

What is an H&P, and Why is it So Important?

Imagine you are a detective. A crime has happened, and you are called to the scene. You wouldn’t just guess who did it. You would look for clues, talk to witnesses, and examine the evidence carefully. You would piece together a story to find the truth. In medicine, every patient is a mystery waiting to be solved. The illness or problem is the “crime.” And the doctor is the detective. The History and Physical, or H&P, is the detective’s complete case file. It is the single most important document in medicine. It is the foundation for everything that happens next.

The H&P is a detailed report. It has two big parts, just like its name says. The History is the story of the patient’s problem, told in their own words and through specific questions. The Physical is the doctor’s hands-on examination of the patient’s body, looking for physical clues. Writing an H&P is not just paperwork. It is a disciplined way of thinking. It forces the medical team to listen, look, and think logically. It helps them go from a confusing set of symptoms (like chest pain and nausea) to a working diagnosis (like a heart attack). Then, it guides all the tests and treatments.

This blog post will walk you through every single part of a complete H&P. We will use a simple example throughout: a patient named Mr. Johnson, a 58-year-old man who comes to the clinic complaining of “heartburn.” We will see how his simple complaint unfolds into a full story. We will break down medical terms into easy, 9th-grade English. By the end, you will see how doctors and nurses use this tool to save lives every single day. This is not just for future doctors; understanding this process can help anyone be a better advocate for their own health or the health of their family.

Section 1: The Chief Complaint (CC) – The Starting Point

Every medical story needs a beginning. The Chief Complaint, or CC, is that starting point. It is a very short statement, in the patient’s own words, that answers the question: “What brings you in today?” The key is to use the patient’s exact words, inside quotation marks. We do not use medical jargon here. If the patient says “my tummy hurts,” we write that, not “abdominal pain.” This keeps the record true to what the patient is feeling. The CC is usually just a few words long. It is the headline of the patient’s story.

For our patient, Mr. Johnson, the Chief Complaint is simple. When the nurse asks why he is here, he says, “I’ve had terrible heartburn for the past three days.” That is exactly what we write: CC: “Terrible heartburn for three days.” This seems straightforward. But already, a good medical detective is thinking. “Heartburn” is what the patient calls it. But is it really just heartburn from a spicy meal? Or could it be a sign of something more serious, like a heart problem? The CC sets the stage for the entire investigation that follows. It is the reason for the visit, the problem we are here to solve.

Sometimes, a patient might have more than one problem. They might say, “My knee hurts, and I’ve been dizzy.” In that case, we list both, but we still use their words. It could look like: CC: 1. “My right knee is killing me when I walk.” 2. “I feel like the room is spinning.” The rest of the H&P will then explore each of these complaints in detail. The CC is like the title of a book. It tells you what the book is about, but you have to read the chapters to understand the whole plot.

Section 2: The History of Present Illness (HPI) – Telling the Whole Story

This is the heart of the detective work. The History of Present Illness, or HPI, is where we tell the complete, detailed story of the Chief Complaint. It is not just one sentence; it is a rich paragraph (or several) that paints a full picture. To do this, doctors use a framework called the “OLD CARTS” mnemonic. It is a checklist to make sure no detail is missed. Let’s break down OLD CARTS and apply it to Mr. Johnson’s “heartburn.”

O – Onset: When did it start? Did it come on suddenly or slowly? Mr. Johnson says it started three days ago, right after he mowed his lawn on a very hot afternoon. It began suddenly, while he was still outside.
L – Location: Where exactly is the problem? He points to the center of his chest, right behind his breastbone. He also feels it radiating, or traveling, to his jaw and down his left arm.
D – Duration: How long does it last when it happens? Each episode of pain lasts about 10-15 minutes. It comes and goes.
C – Character: What does it feel like? Use descriptive words. He says it’s not a burning feeling. It is more like a “heavy pressure” or a “squeezing.” He describes it as “an elephant sitting on my chest.”
A – Aggravating and Alleviating factors: What makes it worse? What makes it better? The pain gets worse when he walks up the stairs. It does not get worse after eating his favorite spicy salsa, which is surprising for classic heartburn. Nothing seems to make it completely better, but resting and sitting still helps a little.
R – Radiation: Does the pain move or travel anywhere? As he said, it goes to his jaw and left arm.
T – Timing: Has it been constant or intermittent? It comes in waves, about 4-5 times a day since it started.
S – Severity: How bad is it on a scale of 0 to 10? He rates it an 8 out of 10 when it is at its worst.

Now, we put all of this together into a narrative HPI paragraph: “Mr. Johnson is a 58-year-old man with a three-day history of substernal chest pressure. The onset was sudden three days ago after mowing his lawn in the heat. He describes the pain as a ‘heavy squeezing’ sensation, like ‘an elephant on my chest,’ which radiates to his jaw and left arm. Each episode lasts 10-15 minutes and occurs 4-5 times daily, aggravated by exertion (walking stairs) and mildly alleviated by rest. It is not associated with eating. He rates the severity as 8/10 at its worst.”

See the difference? The simple word “heartburn” is now a detailed story that sounds much more serious. The HPI is where the detective’s suspicion grows that this might be a heart issue, not a digestive one. A good HPI tells a clear story that almost points to the diagnosis by itself.

Section 3: The Past Medical, Surgical, Social, and Family History – The Background Check

A detective doesn’t just look at the crime scene. They look into the person’s background. In medicine, we do the same. We need to understand the patient’s life and history to see the full picture. This section provides crucial context.

Past Medical History (PMH): This is a list of all the patient’s known long-term illnesses and major past health events. Think of it as their medical resume. For Mr. Johnson, we find out he has hypertension (high blood pressure) for 10 years and Type 2 diabetes for 5 years. He also had pneumonia two years ago. These are big clues. Both hypertension and diabetes are major risk factors for heart disease. We also list his medications: Lisinopril for blood pressure, Metformin for diabetes, and a baby aspirin daily. We note his allergies: He has no known drug allergies (we write this as “NKDA”).

Past Surgical History (PSH): We list all past surgeries, when they happened, and how they went. Mr. Johnson had his appendix removed as a teenager and a cataract surgery on his left eye two years ago, without complications.

Social History (SH): This is about the patient’s life. It is incredibly important. We ask about tobacco use (He smokes one pack of cigarettes a day for 30 years, a huge risk for heart disease), alcohol use (He has 2-3 beers on weekends), occupation (He is a construction manager, a stressful job), and living situation (He lives with his wife). We might also ask about diet, exercise, and travel. This history helps us understand the patient’s risks and their support system.

Family History (FH): Diseases can run in families. We ask about the health of parents, siblings, and children. Mr. Johnson tells us his father died of a heart attack at age 60. His mother has arthritis. This is a critical piece of information. A father with early heart disease greatly increases Mr. Johnson’s own risk. All of this background, the hypertension, diabetes, smoking, and family history, combines to form a perfect storm pointing toward a cardiac problem. It explains why this might be happening to him.

Section 4: The Review of Systems (ROS) – The Complete Body Scan (By Questions)

The Review of Systems is a head-to-toe checklist, done by asking questions. It is like a systematic search for other clues the patient might have forgotten to mention or thought were unrelated. We go through each major system of the body. A positive finding means we note it. A negative review is just as important, it tells us what symptoms are not present.

For Mr. Johnson, we go through the systems:

• General: He reports feeling very tired for the last week. No fever or weight loss.
• HEENT (Head, Eyes, Ears, Nose, Throat): He has had a slight headache with the chest pain. His vision is normal.
• Cardiovascular (Heart): This is the key system. He confirms the chest pain, shortness of breath when walking, and notes his heart sometimes feels like it’s “fluttering.” He denies swelling in his legs.
• Pulmonary (Lungs): He has a mild cough. He denies wheezing.
• Gastrointestinal (Stomach & Intestines): He has no nausea, vomiting, or change in bowel habits. His “heartburn” is not related to food.
• Neurological (Brain & Nerves): He feels a bit lightheaded with the pain. No numbness or weakness elsewhere.
• All others (Skin, Musculoskeletal, etc.): He denies rashes or joint pain.

The positives here, fatigue, shortness of breath, palpitations, lightheadedness, are all symptoms that can go with a heart problem. The fact that his stomach system is negative (no nausea related to eating) makes true heartburn less likely. The ROS helps connect the dots and ensures we don’t miss a symptom that could point to a different diagnosis.

Section 5: The Physical Exam (PE) – The Hands-On Investigation

Now, the doctor moves from listening to looking and touching. The Physical Exam is the hands-on search for physical signs of disease. It follows the same head-to-toe order as the ROS. The findings are recorded in a standard format. Let’s examine Mr. Johnson.

• Vital Signs: These are the key measurements. Mr. Johnson’s are: Blood Pressure 165/95 (high), Heart Rate 110 (fast), Respiratory Rate 22 (fast), Temperature 98.6°F (normal), Oxygen Saturation 94% (slightly low). These abnormal vitals are the first hard evidence that his body is under stress.
• General Appearance: The doctor walks in and notes: “Patient is a well-developed man, appearing stated age, in moderate distress, clutching his chest and breathing rapidly.” This immediate impression is vital.
• HEENT: Pupils are normal. Throat is clear.
• Neck: Neck veins are a bit distended (full), which can be a sign of heart strain. No tenderness.
• Cardiovascular (Heart): This is the focus. Palpation (feeling) finds his heartbeat is fast and strong. Auscultation (listening with a stethoscope) reveals a regular rhythm but fast, with a soft, whooshing sound (a murmur) that wasn’t there before. This is a new, important finding.
• Pulmonary (Lungs): Listening reveals crackles (a subtle crackling sound, like rubbing hair) at the bases of both lungs. This is a sign of fluid buildup, which can happen when the heart isn’t pumping effectively.
• Abdomen: Soft, not tender. Normal bowel sounds.
• Extremities: Hands are cool and sweaty. There is 1+ pitting edema (very mild swelling that leaves a dent when pressed) in his ankles.

The Physical Exam has now provided powerful evidence. The high blood pressure, fast heart rate, new heart murmur, crackles in the lungs, and swollen ankles all paint a picture of a heart that is struggling. This is no longer just a story from the patient; these are objective signs the doctor can see, hear, and feel.

Section 6: Putting It All Together: Assessment & Plan (A&P) – The Diagnosis and Game Plan

This is the conclusion of the detective’s report. The Assessment and Plan is where we summarize what we think is wrong and what we are going to do about it. It is often numbered by problem.

Assessment: This is a list of the patient’s active medical problems, starting with the most likely diagnosis for the current issue. For Mr. Johnson, the doctor writes:
1. Acute Coronary Syndrome (ACS), likely Unstable Angina. This is the medical term for a heart attack or a pre-heart attack condition. The doctor explains to the team: “Given his chest pain character, radiation, and risk factors (hypertension, diabetes, smoking, family history), along with his physical exam findings of pulmonary crackles and edema, the leading diagnosis is a cardiac issue. Unstable Angina is at the top of our list.”
2. Hypertension, uncontrolled. His blood pressure is very high today.
3. Type 2 Diabetes Mellitus.
4. Tobacco Use Disorder.

Plan: For each problem, we list a clear plan.
For #1 (ACS):

• Diagnostics: Get an EKG (electrocardiogram) immediately to check his heart’s electrical activity. Order blood tests called cardiac enzymes (Troponin) to see if there is heart muscle damage. Schedule an echocardiogram (ultrasound of the heart) to see how well it is pumping.
• Therapeutics: Admit him to the hospital. Start him on aspirin (a blood thinner), nitroglycerin (to open up heart arteries), and a beta-blocker (to slow his heart and lower blood pressure). Start him on oxygen via a nasal cannula.
• Patient Education: Explain to Mr. Johnson and his wife that we are very concerned this is his heart. We need to treat it aggressively. He must stop all activity and rest in bed.
  For #2 (Hypertension): Adjust his medications once the heart situation is stable.
  For #3 (Diabetes): Monitor his blood sugar closely while in the hospital.
  For #4 (Smoking): Discuss smoking cessation programs and support. This admission is a critical moment to help him quit.

The A&P turns all the information from the history and physical into actionable steps. It is the blueprint for the patient’s care.

Conclusion: The H&P – More Than Just Notes

The History and Physical is not a boring form to fill out. It is the story of a person’s illness and the map to their healing. For Mr. Johnson, his simple complaint of “heartburn” led to a detailed story of cardiac pain, a background full of risk factors, and a physical exam showing a stressed heart. This comprehensive H&P allowed the medical team to quickly and accurately diagnose a life-threatening condition and start treatment that likely saved his life. It communicated this critical information clearly to every nurse, specialist, and therapist who would care for him.

Learning to do an H&P teaches future doctors, nurses, and physician assistants the most fundamental skill in medicine: how to think. It teaches them to listen completely, observe carefully, and connect the dots logically. Even if you never work in healthcare, understanding this process helps you see how doctors think. It empowers you to tell your own health story more effectively. You can use the OLD CARTS framework to describe your own symptoms clearly. You can keep track of your own past history and family history. Being an informed patient is one of the best things you can do for your health. The next time you visit a doctor, remember you are both detectives, working together to solve the mystery. You provide the history, they perform the physical, and together, you build the case file, the H&P, that leads to the right answer.