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OBJECTIVES/RATIONALE In order to provide adequate client health care, it is necessary to obtain an accurate patient history and physical examination. The student will assist and record results of a patient history and physical. TEKS 121.4 1E, 3C, 6D, 12A, 12C, 13A, 14B, 14C, 16A, 17B TAKS ELA 1, 4 Mathematics 1, 2, 3, 8 Science 2, 3 KEY POINTS I. Information gathered while performing a history and physical on a patient helps the physician determine: A. Patient level of health B. Need for additional testing or examinations C. Tentative diagnosis D. Preventive measures needed E. Type of treatment Length and detail At times the patient’s history may need to be in great detail. For example, when a patient goes to see a specialist the patient may be asked to fill out a very lengthy form about any problem in the past looking for a pattern. But, many times a simple history is all that is needed to give the physician a good idea about what is going on with the patient and the best way to treat it such as a patient seeing a doctor for a sore throat or broken arm. Common components of the patient’s history A. Chief Complaint (CC) - a brief statement made by the patient describing the nature of the illness (signs and symptoms) and the duration of the symptoms. Why the patient came to see the physician. B. History of present illness (HPI) – detail each symptom and looks at the order of the symptoms to occur and the length of each. C. Past History (PH) – all prior illness the patient has had and date of occurrence. 1. Childhood diseases 2. Operations 3. Admission to the hospital 4. Serious injuries and disabilities 5. Shot record (immunizations) 6. Allergies (all kinds including drug reaction)
A. trauma (such as cuts and bruises). therapist. Part or all of the exam may be performed by a nurse. 2. most likely done after the other parts of the exam. drugs. Social and occupational history (SH) – includes information related to the type of job. 2. Example: a nurse or paramedic may check victim’s eyes to see if they are dilated or note that the patient has multiple cuts and bruises. 1. home life. For women only – number of pregnancy. and date of last menstrual cycle D. Palpation – by applying the tips of the fingers. 6. 5. scars. Many times instruments are used to assist in getting a better look such as an otoscope or a tongue blade. coffee. diabetes. It is your responsibility to maneuver draping 7. and the cause are noted. Types 1. Ht and Wt. Diet. . grand parents and in some cases children). Note any signs of rashes. PA or other trained person working under the doctor. Diseases among relatives that are thought to have hereditary tendency are also recorded. resources and support Physical Exam Most of the time. mental conditions and any infectious diseases E. BP. age at death. Auscultation – the process of listening to sounds produced internally. the whole hand. x-rays or more invasive type procedures such as a heart cath. and hobbies 3. Preparing the patient for the exam Patients are usually asked to undress and put on a gown when preparing for a physical examination. etc. kidney problems. number of live births. Mensuration – the process of measuring. Use of tobacco. Clinical measurements include TPR. Inspection – visual observation of the body. Percussion – done by tapping the body lightly but sharply with the fingers when looking for the presence of pus or fluid in a cavity. children. religious convictions 4. exercise. 3. if deceased. alcohol. Family History (FH) – the summary of the health status and age of immediate relatives (parents. Always drape patients so they are covered except for the area to be examined. 4. recent travels to the patient’s personal habits and lifestyle. occupation. Generally a stethoscope is used. Examples are cancer. the physical portion of the exam is performed by the physician.IV. B. the date. sleep. or done by the percussion hammer when checking the reflexes of a patient. Marital history. where the patient lives. deformities or swelling. siblings. Examples include lab work. heart problems. placing both hands to a body part to feel for abnormalities and noting any pain or tenderness. Diagnostic Testing – testing done to give the physician a better look at what is going on inside.
Some commonly used instruments: 1. nasal speculum 4. (This is the most common position and depending on the patient’s chief complaint. Lithotomy – the patient lies on the back. tape measure 9. Dorsal recumbent – the patient lies on back. percussion hammer 5. hemostat 16. 5. ophthalmoscope 6. which is adjusted to a sitting position. The feet are resting on a stool or dangling. The face is turned to one side. Sim’s (lateral) – the patient lies on the left side with the left arm and shoulder front-side down on the bed. cotton balls in antiseptic solution 13. Prone – the patient lies facedown. sponge forceps . with or without a head pillow. legs. face turned to one side and arms above head or along side. knees flexed. legs extended. facing the doctor. The more commonly positions used for examinations: 1. The right leg is flexed against the abdomen. the left knee is slightly flexed. arms across chest or at side. gloves 10. knife handle 14. to maintain maximum cover for the patient as the doctor examines various areas of the body. Sometimes the feet are placed in stirrups. 3. emesis basin 11. curved scissors (Metzenbaum) 17. The right arm is flexed comfortably. tongue depressor 2.C. Horizontal recumbent (supine) – the patient lies flat on back. with soles of feet flat on bed 4. Anatomic position (vertical) – the patient stands upright with feet together and palms forward. Fowler’s – the back rests against the bed. extended. 6. the lower legs are flat on the bed. otoscope 3. Dangling (sitting) – the patient sits upright on the side of the bed. they may not be required to remove clothing. The thighs are straight up and down. 9. The bed section is raised under the knees. A pillow is placed between the patient’s feet and the foot of the bed.) Equipment The equipment needed for examination will depend upon the type of exam. 8. The knees are well separated and flexed. sphygmomanometer (blood pressure cuff) 8. 2. 7. knife blade 15. Knee-chest – the patient is on the knees with chest resting on the bed. stethoscope 7. thermometer 12.
19. Complete Positioning and Equipment Worksheet. 27. tissue forceps suture scissors needle holder hypodermic needle syringe mosquito forceps towel clips towels gauze strips drape or sheet ACTIVITIES I. 21. Zakus Mosby Positioning and Equipment Worksheet ASSESSMENT Completion of Positioning and Equipment Worksheet ACCOMMODATIONS For reinforcement. 22. REFLECTIONS . presenting with flu-like symptoms. using simple equipment and the History and Physical Form. 24. II. 26. 20. 23. MATERIALS NEEDED History and Physical Form Clinical Procedures for Medical Assistant 3rd edition by Shannon M. For enrichment. the student will compare and contrast health histories of two or more patients with the same disease/disorder. the student will outline the components of the history and physical exam.18. Conduct a history and physical on a partner. 25.
T. Wt.History and Physical Name Address Telephone Occupation Case No. Date SS Referred Mother Sisters Tuberculosis Gout Goiter BD Insurance SMWD Family History: Father Brothers Cancer Diabetes Rheumatism Heart Obesity Epilepsy Past History: Diphtheria Chickenpox Typhoid Pneumonia Boils Operations Personal History: Menstrual: Onset Marital: Miscarriages Habits: Alcohol Tea/coffee Sleep Other: Insanity Nephritis Other Measles Mumps Scarlet Fever Smallpox Malaria Gonorrhea Syphilis Tonsillitis Jaundice Infections Nephritis Other Periodicity Abortions Tobacco Meals BM Type Children Drug Water Exercise Duration Sterile Chief Complaint: History of present illness: Ht. R BP . P.
General Appearance: Skin Eyes: Vision Nose Chest Heart Genitalia Diagnosis Treatment Membrane Pupil Throat Breasts Lungs Rectum Ears Fundus Tonsils Abdomen Vagina Prognosis Extremities .
Complete the following statements: A. E. H. G. is a fluid used to lubricate. D. Assemble instruments needed for the examination. b. Answer each statement by placing a (T) for true or an (F) for false in front of each. Cotton balls are soaked in . F. C. B. Gloves are used to protect the The is an instrument used to wrap around the arm to aid in detecting the blood pressure. Follow the general examination rules of the medical facility. date. c. Report time. a. 2. An instrument used to examine the nasal cavity is called a . f. A tongue depressor is used to hold down the . An instrument used to examine the eye is called a . The oroscope is an instrument used to examine the I. Be present in the room unless otherwise instructed. Assist the patient only if necessary. g. is an instrument used to hear the heart beat. All used or soiled equipment must be placed in the proper place according to the policies of the medical facility. . Stand by to help position or hold the patient as the doctor requests. d. and the extent of the examination for charting.Positioning and Equipment Worksheet 1. e.
Supine 5. e. With the head and back elevated to quite a high angle on the bed and the knees flexed. Vertical 10. Lying on the left side with left arm behind the back and right leg drawn up and apart from the left h. Lying on the back with one pillow under the head and with the knees flexed (bent) and separated. The patient lies flat on the abdomen with head turned right or left b. a. Sim’s 4. f. Prone 3. Lying flat on the back without a pillow and the knees slightly apart. Fowler’s 8. Outstretched on the back. Match the terms on the right with the definition on the left in relation with positioning the patient. With the head and back somewhat elevated and the knees flexed slightly. Standing upright with good posture and arms at ease by the sides. i. d. Semi-Fowler’s .3. 1. Jackknife 7. Dorsal Recumbent 6. horizontal recumbent 2. g. Dangling 9. j. This position is also called the kneechest position c. Sitting in the side if the bed with the feet hanging.
Ophthalmoscope c. f. Hands f. c. e. Tongue b. Lubricant e. g. i. d. Antiseptic solution a. Nasal speculum d. True True False True True True True a. g. b. f. d. 2. Blood pressure cuff g. Ear i. j. a.KEY Positioning and Draping the Patient For the Medical Examination 1. h. b. Stethoscope h. 3. 2 6 9 1 4 5 3 7 10 8 . e. c.
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