Clinical Medical AssistingChapter 6: Medical History, Patient Screening, and Exams

Objectives• Explain the purpose of a medical history

• List three functions to complete prior to a patient’s appointment

• Discuss the medical assistant’s general approach to the patient intake interview

• List the characteristics of the patient’s chief complaint and the present illness

• Discuss normal and abnormal temperatures and factors affecting body temperature

• Identify and describe normal and abnormal pulse and respiratory rates and the factors affecting each

• Describe the appropriate equipment and procedure for obtaining a blood-pressure measurement

• Identify normal and abnormal blood pressure and factors affecting blood pressure

• Accurately record measurements on the patient’s chart or electronic medical record

• Describe six methods used in physical examinations

Objectives (con’t)

Chapter OverviewA thorough medical history and physical examination are essential for gathering sensitive information and providing appropriate patient care. By completing accurate assessments, you will build strong patient relationships and direct clinical thinking. A poor or incomplete history and physical examination will lead to poor or incomplete care. Likewise, a comprehensive history and physical examination will lead to comprehensive and complete patient care.

Medical History

The clinically relevant information obtained from the patient during a structured interview, usually prior to a physical examination.

Identifying Data

The first item to note when obtaining a medical history is the date and time of the history.

Chief Complaint

The issue or issues for which the patient is currently seeking care.

Present Illness

The description of the present illness (PI) expands the CC and explains how and when each symptom developed.

Past Medical History

Identify the patient’s past medical history (PMH), which summarizes the patient’s health status prior to the PI.

Family History

Outlines the age and health, or age and cause of death, of siblings, parents, grandparents, children, and grandchildren.

Documents the presence or absence of specific family illnesses.

Review of Systems

As part of the medical history, the review of systems (ROS) documents the presence or absence of common symptoms associated with each major body system.

General

Note any recent changes in weight, or even if the patient notes that his or her clothes fit differently than before.

Skin

Note if the patient complains of rashes, lumps, sores, dryness, itching, color changes, or hair or nail changes.

Head, Eyes, Ears, Nose, Throat

Note the presence or absence of headache, dizziness, or lightheadedness.

Neck

Note lumps, pain, or stiffness.

Breasts

Note lumps or pain in the breasts and any nipple discharge.

Respiratory

Note cough, sputum, shortness of breath, and wheezing.

Cardiovascular

Note chest pain or discomfort, palpitations, and edema.

GastrointestinalNote trouble swallowing, indigestion, changes in appetite, nausea, vomiting, bowel movements, hemorrhoids, constipation, diarrhea, abdominal pain, and belching or passing gas.

UrinaryNote the frequency of urination, changes in urination, pain on urination, blood in the urine, and incontinence.

Genital

For all patients, note sexual orientation or preference, interest in sexual activity, and pain associated with sexual intercourse.

Musculoskeletal

Note muscle or joint pain or stiffness, arthritis, and back pain.

Neurologic

Note fainting, seizures, blackouts, paralysis, numbness, tingling in the extremities, and tremors.

Hematologic

Note bruising, excessive bleeding, and transfusions.

Endocrine

Note intolerance to heat or cold, excessive sweating, excessive thirst, excessive hunger, excessive urination, and changes in shoe size

Psychiatric

Note nervousness, anxiety, mood, memory changes, irritability, changes in concentration, sources of stress, and suicide attempts.

Patient Interview

When interacting with patients, the medical assistant must put the patient at ease to facilitate information gathering.

Before the InterviewPrior to seeing the patient, ensure that the examination room is clean and ready for the patient and gather all necessary supplies that will be needed for the interview and the physical examination.

During the InterviewThe interview should be conducted in the privacy of an examination room with the door closed and the patient comfortable.

After the InterviewAfter the patient interview is complete and the medical history has been obtained, the patient should be prepared for the physical examination.

Physical ExaminationA complete physical examination, often simply called a “physical," is performed to assess the general health status of a patient.

Examination Techniques

The six basic techniques provides objective information about the condition of a body system or organ.

Inspection

Is evaluation using sight.

Palpation

Is evaluation using touch.

Percussion

Is the process of producing sounds by tapping on body parts.

Auscultation

Is evaluation by listening.

Examination Positions

Various patient positions are required for the physical examination.

Examination Format

Every provider may approach the physical examination with a slightly different format or technique.

Skills for the Medical Assistant

As a medical assistant, it will likely be one of your primary responsibilities to obtain patient histories and assist with physical examinations.

Measure Height and Weight

Height and weight are not considered vital signs, but are important and routinely obtained during physical examinations.

Measure Oral Temperature

Many factors influence body temperature.

Measure Rectal Temperature

Rectal temperatures are commonly obtained in young children or patients who are unable or unwilling to cooperate with an oral measurement.

Measure Axillary Temperature

Axillary temperature is measured underneath the arm.

Measure Aural Temperature

An aural temperature is assessed in the ear canal with the use of a tympanic thermometer.

Measure Body Temperature with a Temporal Artery Thermometer

A temporal artery thermometer offers a noninvasive means of assessing body temperature.

Measure Radial Pulse and Respirations

The pulse is easily felt at points on the body where an artery is close to the surface of the skin and a solid structure, such as a bone.

Measure Apical Pulse

Apical pulse is measured in patients with known heart-rate dysfunction or irregularity.

Measure Blood Pressure

Blood pressure is measured by auscultation using a stethoscope and a sphygmomanometer.

Prepare a Patient for and Assist with a Physical Examination

As a medical assistant, one of your primary responsibilities on a daily basis will likely be preparing for and assisting with physical examinations.

Summary• A medical history and physical examination gather health

information and guide the physician’s assessment and plan for patient care.

• When interviewing the patient, maintain a professional demeanor.

• Obtain the patient’s height, weight, blood pressure, pulse, respiratory rate, and body temperature before the examination begins. Many factors influence accurate measurements.

• Accuracy and precision in measurements is essential