The Complete History and Physical Exam Guide

The Complete History and Physical Exam Guide

By Eric H. Hanson, MD, MPH, Headquarters United States Air Force, Office of the Surgeon General, Directorate of Modernication, Science and Technology Division, Chief, Science and Technology and Operational Biotechnology, Bolling Air Force Base, Washington, D. C.; and Thomas S. Neuhauser, MD, Staff Pathologist, Medical Directory of Hematology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas

"I. H&P Essentials
1. History and Physical Examination (H&P) Essentials (H&P)
2. Recording Laboratory Values and Diagnostic Information, and Conversion Tables (LAB)
3. Assessment and Plan (A&P) Formulation (A&P)
4. Chartwork Guidelines (CHART)
5. Presentation Guidelines (PRES)
6. Death Certification (DEATH)

II. Specialty-Focused History and Physical Examinations (Specialty H&P's)
7. Allergy and Immunology (ALLERGY)
8. Anesthesiology (ANESTH)
9. Cardiology (CARD)
10. Dermatology (DERM)
11. Emergency Medicine (Trauma Assessment) (EMERG)
12. Endocrinology (ENDO)
13. Gastroenterology (GI)
14. Gynecology (GYN)
15. Hematology (HEME)
16. Infectious Disease (ID)
17. Internal Medicine /Family Practice (IM/FP)
18. Intensive Care Unit (Adult Critical Care Medicine) (ICU)
19. Neonatology (NEO)
20. Nephrology (NEPH)
21. Neurology (NEURO)
22. Obstetrics (OB)
23. Occupational Medicine (OCC)
24. Oncology (ONC)
25. Ophthalmology (OPHTHO)
26. Orthopedics (ORTHO)
27. Otolaryngology (Head and Neck Surgery)/Ear, Nose and Throat (ENT) Surgery (OTO)
28. Pathology (PATH)
29. Pediatrics (PEDS)
30. Preventive Medicine (PREV)
31. Psychiatry (PSYCH)
32. Pulmonology (PULM)
33. Surgery (Focus on General Surgery) (SURG)
34. Urology (URO)

III. Focused History and Physical Examinations (Focused H&P's)
35. Alcohol Screening (ETOH)
36. Epidemiology (EPI)
37. Ethical Considerations (ETHICS)
Informed Consent
Advanced Directives
Do-Not-Resuscitate (DNR) Orders
38. Nutritional Status Evaluation (NUTRIT)
39. Tobacco Screening (TOB)