2.2 Comprehensive History and Physical

A comprehensive history and physical is a structured, whole-person database. The FNP uses it when the existing record cannot support safe decisions: new patients, periodic health maintenance, preparticipation or school/sports physicals, Medicare Annual Wellness Visits (AWV), some preoperative or “establish care” visits, and any encounter that must reset the problem list. A focused visit answers a chief concern. Mixing the two is a common Domain I trap. A 68-year-old who booked “my back hurts since yesterday” does not need a first-time pelvic exam before you examine the spine — unless she is also new, has no record, and you have explicitly converted the visit after the dangerous back-pain questions are asked.

When the comprehensive exam is the right tool

The Medicare AWV is frequently misremembered. CMS does not require a complete head-to-toe physical, pelvic exam, or rectal exam as the definition of an AWV. It does require a health-risk assessment, medical and family history, current providers and suppliers, medication review, height/weight/BMI and blood pressure, depression screening, functional ability and safety, a cognitive assessment, a written screening schedule, and personalized health advice. If you also perform a problem-oriented exam that day, document both services honestly. Billing a comprehensive physical you did not do — or skipping cognition and function because you did a “full physical” — both fail the skill.

Sports and school physicals are comprehensive with a different accent. Cardiac clearance questions (exertional chest pain, unexplained syncope, family sudden death in a young relative, known cardiomyopathy) and a targeted musculoskeletal exam are not optional extras. Signing the form without those items is an incomplete assessment.

History: the complete database

Build the history in a consistent order so a domain does not vanish under time pressure.

1. Identifying data and reliability. Age, sex and gender identity, preferred name and pronouns, historian (patient, parent, caregiver), interpreter use, and whether the historian is reliable.
2. Chief concern (CC). The patient's words. Even a wellness visit has a CC (“here for a physical”; “I want labs”).
3. History of present illness (HPI). Use OLDCARTS: Onset, Location, Duration, Character, Aggravating and alleviating factors, Radiation, Timing, Severity, plus associated symptoms. For wellness, the HPI may be a brief review of interval events since the last comprehensive visit. Do not hide a new chest-pain story inside a 14-point ROS.
4. Past medical history (PMH). Diagnoses, hospitalizations, childhood illnesses, obstetric history using GTPAL (gravida, term, preterm, abortions, living), immunizations, and preventive studies already done with dates. “I had a normal colonoscopy sometime in my 40s” is not a date.
5. Past surgical history (PSH). Procedures, anesthesia problems, implants, dates, residual hardware.
6. Medications and allergies. Prescription, OTC, supplements, contraceptives, leftover or shared opioids. Record the reaction type (hives versus anaphylaxis versus stomach upset). Reconcile the bottle, the pharmacy list, and what the patient actually swallows.
7. Family history (FH). First-degree relatives: atherosclerotic disease before 55 in men or 65 in women, sudden death, breast/ovarian/colon/prostate clusters, diabetes, lipid disorders, psychiatric illness, clotting, and kidney disease. A three-generation sketch is enough to trip most primary-care genetic-risk flags.
8. Social history (SH). Occupation and exposures, relationships, sexual history (partners, practices, protection, past STIs, pregnancy intention, PrEP/PEP need), substances (tobacco and vape, alcohol, cannabis, nonprescribed opioids, stimulants), firearms in the home and how they are stored, housing and neighborhood safety, food security, transportation, education, legal stressors, military service, and spiritual supports. These are Assessment-domain skills, not optional rapport. The October 30, 2026 TCO names SDOH and sexual risk explicitly — do not save them for a “social work” page you never open.
9. Review of systems (ROS). A comprehensive ROS is a head-to-toe symptom inventory by system. It uncovers hidden problems and supports a comprehensive E/M service. It is not a second HPI. Once a ROS item becomes a problem, move the detail into HPI or PMH. Copy-forward positives from last year are a liability.

Developmental history (milestones, school performance, IEP), menstrual detail, and immunization dates are part of the comprehensive history at the appropriate age. They are not extras you add if time remains.

Physical examination

Start with the general survey: appearance, distress, affect, hygiene, mobility aids, skin color, work of breathing, and interaction with a caregiver. Then collect age-appropriate vitals: blood pressure with a correct cuff (both arms at least once in adults when feasible), heart rate, respiratory rate, temperature when indicated, oxygen saturation when cardiopulmonary disease or distress is possible, a pain score, and height, weight, and BMI. In infants and children add length or height, weight, and head circumference, and plot percentiles (WHO charts from birth to 2 years, then CDC). In older adults add orthostatic vitals when falls, syncope, or volume depletion are in play.

Move through systems with a purpose: skin; HEENT and neck; nodes; heart; lungs; abdomen; musculoskeletal including gait and spine; neurologic (mental status plus targeted cranial nerves, strength, sensation, and reflexes); and psychiatric observation (mood, affect, thought, insight). You are building a baseline, not performing every special test known to a textbook.

Sensitive examinations

Breast, pelvic/speculum/bimanual, genital, prostate/rectal, and testicular exams are not automatic at every comprehensive visit. They require an indication or screening purpose, informed consent, a chaperone offered (and documented if declined), privacy, draping, and a trauma-informed script: what you will do, why, that the patient can pause or stop, and that a support person or interpreter can stay if wanted. Do not perform a pelvic exam solely “because it is an annual.” Cervical screening may not require a bimanual exam. A rectal exam is indicated when you are evaluating prostate symptoms, rectal bleeding, or a live cauda equina hypothesis — not as a ritual add-on to a well visit.

Screens that belong in the comprehensive visit

The comprehensive visit is where you place developmental tools (Ages and Stages, M-CHAT-R/F in the 18- and 24-month windows), functional assessment (ADLs/IADLs, fall risk, vision and hearing), and cognitive screens (Mini-Cog or a similar instrument when the AWV or clinical concern calls for one). Depression, anxiety, substance, and intimate-partner-violence screens also live here. Chapter 3 develops functional and risk assessment in depth. The skill in this section is remembering that those instruments are part of the comprehensive database for the right age, not a specialty referral by default and not something you skip because the patient “came for labs.”

Documentation, billing, and medical-legal completeness

If it is not in the note, it was not done. A comprehensive note should let another FNP reconstruct who was present, the historian, consent and chaperone for sensitive exams, reconciled meds and allergies, the problem list you accepted or added, pertinent negatives that make red-flag diagnoses unlikely, the screening calendar you generated, and the follow-up plan. Copy-forward EHR residue that still lists last year’s “positive ROS: chest pain” is both unsafe and an audit problem. For coding, the history and exam must match the service billed. A problem visit padded with an unused 14-point ROS is not comprehensive care.

Vignette: 52-year-old woman, new, no records

L.M. is 52. She recently moved states, has no portal records, feels “fine,” and wants “bloodwork.” A focused “labs only” visit would miss the Assessment-domain job.

History you must build. CC: establish care and prevention. HPI/interval: last known Pap about 8 years ago and “normal,” no colonoscopy, last mammogram “maybe at 45,” smokes 8 cigarettes daily for 20 years (0.4 pack/day × 20 = 8 pack-years, so she is not LDCT-eligible), drinks 4–5 glasses of wine most nights, sexually active with one male partner without condoms, last HIV test unknown, two adult children, last menstrual period 14 months ago (possible menopause), no hormone therapy. PMH: “borderline sugar,” no medications. PSH: appendectomy at 19. Allergies: penicillin → hives. FH: mother with breast cancer at 61, father with MI at 58. SH: apartment with a partner, no firearms, food secure, night-shift warehouse work, PHQ-2 score 3.

Exam. Vitals (BP 148/92, repeat 146/90), BMI 31, general survey, heart, lungs, abdomen, brief musculoskeletal and neurologic exams. Offer a breast exam only after consent and a risk discussion — a mother with breast cancer at 61 is a family-history flag, not an automatic MRI pathway. Perform a pelvic exam only if you are doing indicated cervical sampling and she consents, with a chaperone offered.

Assessment output. You now have a new-patient database: untreated tobacco and likely unhealthy alcohol use; overdue cervical, breast, and colorectal screening; possible menopause; elevated BP that needs out-of-office confirmation; a positive depression screen; undocumented HIV and HCV; and a family history that informs counseling but does not by itself create a high-risk-clinic breast protocol. The comprehensive visit is finished when that plan exists, not when a CBC prints.