History & Physical Exam
The History and Physical Exam, often called the "H&P" is the starting point of the patient's "story" as to why they sought medical attention or are now receiving medical attention.
The History portion contains the chronology of what is wrong with the patient - often the "what is wrong with the patient" is called the "chief complaint" and is often abbreviated "CC" in the History documentation in the medical record. For example, a patient may report that there is blood in her sputum and this has been present for a period of one week. The physician will often write: CC: "Patient reports blood in sputum for a period of one week."
Following the chief complaint, the physician will also document any other pertinent History about the patient's medical, behavioral, and psycho-social aspects.
Following the History, the physician SHOULD then perform a Physical Exam (or "PE"). The Physical Exam includes both objective and subjective assessments of the patient's physical being. Documentation of the Physical Exam is typically grouped by body system, such as Head, Eyes, Ears, Nose and Throat (often abbreviated "HEENT"), Respiratory, Genito-Urinary, etc. Objective medical measurements such as blood pressure, pulse rate, temperature, etc. are made and documented. There are also many subjective measurements made during the PE, such as visual observation and palpation, often with "best judgment" assessments as to size, location, and involvement of any abnormal finding.
Common Physical Exam Procedures
Key information (information to look for and pay attention to and to document with regard to collecting pertinent information about the patient's cancer):
Obvious lesions; palpable mass(es); ulceration; size (in centimeters or inches) and location (especially if tumor crosses midline) of primary tumor(s); swelling or enlargement of any masses or organs (organomegaly, hepatomegaly, splenomegaly, hepatosplenomegaly/HSM); fixation of mass; invasion/erosion of bone; laterality, size and number of palpable lymph nodes, especially cervical, supraclavicular, axillary or inguinal; evaluation of cranial nerves; evidence of "frozen" pelvis. For lymphoma, involvement of lymph nodes (matted nodes, fixed vs. mobile, lymphadenopathy, enlarged, "shotty" nodes, palpable, enlarged, visible swelling). For central nervous system tumors, neurologic examination for signs and symptoms (which help identify the location of the tumor); vision changes; attention deficit; focal deficit (blindness, taste aberrations); tumor impingement on a specific nerve or structure; mass effect (light-headedness, loss of vision); evidence of increased intracranial pressure (edema, headache, nausea and vomiting); evidence of obstructive hydrocephalus.
Digital Rectal Examination
Manual or digital examination of the lower portion of the rectum, perineum and surrounding tissues using a gloved finger inserted into the anus. During the examination, the examining finger can feel the prostate gland. Also called DRE, rectal exam, manual exam.
Key words/possible involvement:
Nodularity, palpable tumor, induration, fixation of seminal vesicles, enlargement, firmness, lesion, fixation to surrounding tissues, neoplasm, malignancy, active bleeding.
Other words/no involvement:
If there is no mention of prostatic abnormality during the exam; benign prostatic hypertrophy.