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Chapter 16 Medical History and Patient Assessment 321
Medical records of patients who have had a mastectomy or who have a dialysis shunt should clearly show
that no blood pressure measurements or blood draws
are to be performed on the designated arm. You should
be able to use the other arm to measure blood pressure.
Most patients are aware of the importance of not taking blood pressure or specimens from the affected arm.
Although they will probably alert you before you make a
mistake, it is always best to check the medical record rst.
Normal Blood Pressure
The average adult blood pressure is 120/80. Athletes
may have a lower normal blood pressure because their
Figure 16-13 Choosing the right blood pressure cuff.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting. 5th
ed. Philadelphia, PA: Wolters Kluwer; 2016.)
the loss of any sounds for a drop of up to 30 mm Hg
after the rst sound is heard.
You need to be aware of the possibility of this gap.
It can lead to errors in blood pressure readings. The last
sound heard at the beginning of the gap may be inaccurately recorded as the diastolic pressure. It is important
to watch the dial or column liquid carefully until you
are sure you have heard the last sound before noting the
diastolic pressure.
Pulse Pressure
The difference between systolic and diastolic readings is
called the pulse pressure. For the average adult blood pressure of 120/80, the pulse pressure is 40 (120 − 80 = 40).
The normal range for pulse pressure is 30 to 50 mm
Hg. As a general rule, the pulse pressure should be no
more than one-third of the systolic reading. If the pulse
pressure is much larger or smaller, you need to notify
the physician.
Patients with Shunts and Mastectomy
cardiovascular systems are highly conditioned.
Sometimes, blood pressure drops suddenly when the
patient moves from a sitting or lying position to a standing position. This drop is called postural hypotension or
orthostatic hypotension. It can cause symptoms such as
vertigo, or dizziness. It also may cause fainting. Be careful when asking patients to change from lying down to
sitting or standing, and remind patients to move slowly.
Diseases Affecting Blood Pressure
Blood pressure readings depend on the elasticity of the
artery walls, the strength of the heart muscle, and the
quantity and thickness of the blood. Any diseases that
affect these body structures will affect blood pressure
readings. Some diseases affect the size and elasticity of
the arteries.
Arteriosclerosis refers to a number of diseases that
r
cause narrowing and hardening of the artery lumen,
the space inside the arteries. Arteriosclerosis causes
artery walls to thicken and lose elasticity.
Atherosclerosis is a specic type of arteriosclerosis
r
in which plaque builds up in the linings of arteries.
Plaque is deposits of fatty substances and cholesterol.
These deposits cause arteries to narrow and harden,
reducing blood ow.
Some patients require special attention when taking
blood pressure.
A dialysis shunt is a surgically made access port that
r
allows a patient with little or no kidney function to be
connected to a dialysis machine. Taking blood pressure in the arm with the shunt could permanently
damage the shunt. Do not use the arm that has an
implanted shunt. If the shunt is damaged, the patient
cannot receive dialysis until a surgeon puts in a new
shunt.
Patients who have had a mastectomy (surgery to
r
remove a breast) should also not have blood pressure
taken in the arm on the affected side. That side of the
body may have impaired circulation because of the
surgery.
How Health Affects Blood Pressure
Sometimes, a patient’s family history can be a factor in
a patient’s blood pressure, but good general health practices can help keep the arteries and the heart healthy.
Some general health practices and patient history that
may affect blood pressure include the following:
Dietary habits
r
Alcohol use
r
Tobacco use
r
Exercise habits (amount and type of exercise)
r
Previous heart conditions
r
Along with the patient’s general health, there are many
other factors that can affect blood pressure readings.
322 Section IV Clinical Medical Assistant Skills
Age—As the body ages, blood vessels begin to lose
r
elasticity. More force is needed to expand artery walls.
The buildup of plaque from the process of atherosclerosis also increases the force needed for blood ow.
Activity—Exercise temporarily raises blood pressure.
r
Inactivity or rest usually lowers the pressure.
Weight—People who are obese, or even just over-
r
weight, are at increased risk for developing high
blood pressure.
Stress—During stress, the body releases a hormone
r
called epinephrine (also known as adrenaline). This
hormone increases the heart rate and raises the blood
pressure.
Body position—Blood pressure normally lowers
r
when a person is supine, or lying down on her back.
Medications—Some medications lower blood pres-
r
sure and others may raise it.
So many factors can affect blood pressure. Physicians
usually diagnose high blood pressure when there have
been three or four elevated readings over a period of
time.
What Can Go Wrong
As a medical assistant, you need to be concerned about
getting accurate assessments of vital signs. If you do get
a reading that is not within normal limits, recheck the
blood pressure before reporting it. You might have made
an error. There are many possible sources of errors in
taking blood pressure readings. It is important to be
aware of them—and to try to avoid them. Sources of
errors include:
Newborn Vital Signs: The Apgar Score
The Apgar score is a method for describing the general
health of newborns at 1 and 5 minutes after delivery.
Vital sign measurements are part of the Apgar score.
Obstetricians, pediatricians, and delivery room personnel use this score to assess newborns who may need to
be watched more closely. Five signs are assessed:
Heart rate
r
Respiratory effort
r
Muscle tone
r
Response to a suction catheter in the nostril
r
Color
r
A perfect score for each sign is two. A total absence
of any sign is zero. A perfect Apgar score of 10 indicates
all of the following things about a newborn:
Heart rate is >100 beats/min.
r
Respirations are good and the infant is breathing nor-
r
mally or the baby is crying.
Muscle tone is good and the baby is active.
r
Baby coughs or sneezes in response to the suction
r
catheter.
Skin is pink, with no acrocyanosis (blue color in the
r
extremities).
Most babies have 1-minute scores of 7 to 9. Many
may have a bit of acrocyanosis until their respiration is
fully established. Babies with 1-minute scores of <4 usually require medical assistance. They often need oxygen
to help them with their breathing.
Wrapping the cuff improperly.
r
Failing to keep the patient’s arm at the level of the
r
heart while taking blood pressure readings.
Failing to support the patient’s arm on a stable surface
r
while taking a blood pressure reading.
Recording the auscultatory gap as the diastolic
r
pressure.
Failing to keep the pressure gauge at eye level.
r
Applying the cuff over the patient’s clothing and
r
attempting to listen through clothing.
Allowing the cuff to deate too rapidly or too slowly.
r
Failing to wait 1 to 2 minutes before rechecking the
r
same arm.
Using the wrong size cuff can cause an error as much
r
as 30 mm Hg.
Study Skill
Some students nd that they learn material and
have better retention of information when they
develop their own quizzes. Write a few (4 to 5) questions based on information from the lesson or the
chapter. Multiple-choice questions are the easiest to
write. Give 4 or 5 possible answers with only one
being the correct answer. Write each question on
an index card. After completion of a few chapters,
you will have a collection of questions you can use
for your course exam, nal exam, or national certication exam review. As you write these questions,
you will be reinforcing the correct answer for future
recall.
Chapter 16 Medical History and Patient Assessment 323
Procedure 16-1
Interviewing the Patient to Obtain a
Medical History
1. Gather the supplies you need—a medical history
form or questionnaire in electronic or paper format. If using paper format, you will also need a
black ink pen.
2. Review the medical history form before you speak
to the patient so that you are familiar with the
order of the questions and the type of information
needed.
3. Take the patient to a private and comfortable area
of the ofce. You want to ensure condentiality
and prevent distractions.
4. Face the patient so you are both at the same eye
level. Standing above the patient may make the
patient feel threatened or uncomfortable.
P
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5. Introduce yourself providing your name and title,
and explain the purpose of the interview.
6. Ask the appropriate questions and document the
patient’s responses. Make sure you determine the
CC and PI.
Be sure to use language and words the patient
r
can understand.
No matter what the patient tells you, be
r
professional.
Take care that your words and actions do not
r
show judgmental attitudes. You want your
patient to trust you.
7. Maintain frequent eye contact to show that you are
listening. This reassures the patient you are interested in what she is saying.
8. If appropriate, explain to the patient what to expect
during the medical examination or procedures.
Keeping the patient informed may help decrease
anxiety.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins' Comprehensive
Medical Assisting. 5thed. Philadelphia, PA: Wolters
Kluwer; 2016.)
9. When the interview is nished, thank the patient
for cooperating. Offer to answer any questions the
patient may have.
324 Section IV Clinical Medical Assistant Skills
Procedure 16-2
Document a Chief Complaint and
PresentIllness
1. Gather supplies, including the patient’s medical
record containing a cumulative problem list or
progress note form.
Fred Smart 09-15-1945
No
Yes
Penicillin
Multivitamin
1 tablet
every day
Beer
I can’t remember
Last year, I cut my finger when fishing.
P
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Y
2. Review the new or established patient’s medical
history form. Being as familiar as possible with
the patient will help you get complete information
about the CC and PI.
Physical Exam
2-3
Every week
No
No
1952-childhood? Tonsillectomy
Spring, 1999
Pneumonia
Cut my finger while fishing last year. I had a broken leg from a car accident in 1984.
No
(Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins'
Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 16 Medical History and Patient Assessment 325
Procedure 16-2
Document a Chief Complaint and
PresentIllness
Cigarettes
1 pack a day
(continued )
20 years
Grandmother had colon cancer; Father has high blood pressure
Married for 30 years
Mail Carrier
Graduated high school 1963
Fishing, camping
(Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins'
Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
3. Greet the patient by name and escort him to the
examination room. Using the patient’s name helps
develop rapport and may ease any patient anxiety. Correctly identifying the patient also can help
prevent mistakes.
4. Use open-ended questions to nd out why the
patient is seeking medical care. Be sure to maintain eye contact so the patient is aware that you are
actively listening.
5. Determine the PI using open-ended and closedended questions. Use several open-ended questions
rst. Then, use closed-ended questions to get more
specic information.
6. Document the CC and PI on the cumulative problem list or progress report form. Include the date,
time, CC, PI, and your signature (rst initial, last
name, and title). Use only correct medical terminology and approved abbreviations.
7. When you have nished asking questions, thank the
patient for cooperating. Explain that the physician
will be in soon for the examination. If you give a time
frame about when the physician will arrive, be honest.
326 Section IV Clinical Medical Assistant Skills
Procedure 16-3
Measuring Oral Temperature Using a
Mercury-Free Glass Thermometer
1. Gather the following supplies: a glass mercury-free
oral thermometer with a blue top, a disposable
plastic sheath, tissues or cotton balls, disposable
exam gloves, a biohazard waste container, and disinfectant solution. Then, wash your hands and put
on gloves.
2. Dry the thermometer if it has been stored in a
disinfectant solution. To dry the thermometer, use
tissues or cotton balls to wipe the thermometer
from the bulb up the stem. A dry thermometer will
slip easily into the sheath.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4thed. Philadelphia, PA: Wolters
Kluwer; 2013.)
3. Carefully check the thermometer for chips or
cracks. A damaged thermometer could injure the
patient.
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6. Insert the thermometer into the plastic sheath.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
7. Greet the patient by name. Explain the procedure
and ask about any eating, drinking of hot or cold
uids, gum chewing, or smoking within the last
15minutes.
Any of these could alter the oral reading.
r
Wait 15 minutes before taking the reading or
r
choose another method.
8. Place the thermometer under the patient’s tongue
to one side of the frenulum, a small strip of tissue
that connects the tongue to the oor of the mouth.
This area has the highest blood ow and will give
the most accurate reading.
4. Check the thermometer reading. Hold the stem at
eye level and turn it slowly to see the liquid in the
column.
5. If the reading is above 94°F, shake down the thermometer. The liquid inside must be below 94°F to
provide an accurate temperature reading.
Grasp the thermometer carefully at the end of
r
the stem using your thumb and forenger.
Snap your wrist several times.
r
Be careful not to hit the thermometer against
r
anything when snapping your wrist.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
Chapter 16 Medical History and Patient Assessment 327
Procedure 16-3
Measuring Oral Temperature Using a
Mercury-Free Glass Thermometer
9. Ask the patient to keep the mouth and lips closed.
This prevents air from entering the mouth and
causing an inaccurate reading. Remind the patient
not to bite down on the thermometer.
10. Leave the thermometer in place for 3 to 5 minutes.
Three minutes is long enough if the patient has
r
no evidence of fever.
If the patient is noncompliant and frequently
r
talks or opens her mouth, the thermometer
should be left in place for 5 minutes.
It also should be left in place for 5 minutes if the
r
patient is febrile.
While you are waiting for a temperature reading,
r
you can take the patient’s pulse, respirations, and
blood pressure.
11. When the time is up, remove the thermometer from
the patient’s mouth. Be sure to wear gloves.
(continued )
12. Then, remove the sheath by holding the edge of the
sheath with the thumb and forenger of one hand
and pulling down from the open edge over the
length of the thermometer to the bulb. The soiled
area should now be inside the sheath. Discard the
sheath in a biohazard waste container.
13. Hold the thermometer horizontal at eye level. Note
the level of liquid that has risen into the column.
14. Sanitize and disinfect the thermometer according to
ofce policy. Remove your gloves and then wash
your hands.
15. Record the temperature reading in the patient’s
medical record. Remember, procedures are not
considered done if they are not recorded. The vital
signs are usually recorded together.
Procedure 16-4 Measuring a Rectal Temperature
1. Gather the following supplies: a glass mercury-free
rectal thermometer with a red top, a disposable
plastic sheath, tissues or cotton balls, disposable
exam gloves, a biohazard waste container, lubricant, and disinfectant solution. Then, wash your
hands and put on gloves.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
4th ed. Philadelphia, PA: Wolters Kluwer; 2013.)
2. Dry the thermometer if it has been stored in a
disinfectant solution. To dry the thermometer, use
tissues or cotton balls to wipe the thermometer
from the bulb up the stem. A dry thermometer will
slip easily into the sheath.
3. Carefully check the thermometer for chips or
cracks. A damaged thermometer could injure the
patient.
4. Check the thermometer reading. Hold the stem at
eye level and turn it slowly to see the liquid in the
column.
5. If the reading is above 94°F, shake down the thermometer. The liquid inside must be below 94°F to
provide an accurate temperature reading.
Grasp the thermometer carefully at the end of
r
the stem using your thumb and forenger.
Snap your wrist several times.
r
Be careful not to hit the thermometer against
r
anything when snapping your wrist.
6. Insert the thermometer into the plastic sheath.
7. Spread lubricant onto a tissue and then from the
tissue onto the sheath of the thermometer. Do not
apply lubricant directly onto the thermometer.
Lubricant should always be used for rectal insertion to prevent patient discomfort.
P
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328 Section IV Clinical Medical Assistant Skills
Procedure 16-4 Measuring a Rectal Temperature (continued )
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
8. Greet the patient by name and explain the
procedure.
9. Ensure the patient’s privacy by placing the patient in
a side-lying position facing the examination room
door, if possible. If the door is opened, a patient
facing the door is less likely to be exposed. Drape
the patient appropriately. The side-lying position
facilitates exposure to the anus.
10. Visualize the anus by lifting the top buttock with
your nondominant hand. Never insert the thermometer without rst having a clear view of the anus.
11. Gently insert the thermometer past the sphincter
muscle. The thermometer should be inserted about
1.5 inches for an adult, 1 inch for a child, and
0.5inch for an infant.
12. Release the upper buttock and hold the thermometer in place with your dominant hand for
3 minutes. The thermometer will not stay in place
if you do not hold it. Replace the drape to ensure
the patient’s privacy, but don’t move your dominant hand.
13. After 3 minutes, remove the thermometer and
sheath. Discard the sheath in a biohazard waste
container. You need to remove the sheath before
reading the thermometer to get an accurate reading.
14. Hold the thermometer horizontal at eye level and
note the temperature reading.
15. Give the patient a tissue to wipe away excess
lubricant.
16. Sanitize and disinfect the thermometer according to
ofce policy. Then, remove your gloves and wash
your hands.
17. Record the temperature reading in the patient’s
medical record. Be sure to mark the letter “R” next
to the reading, to show the temperature was taken
rectally. Temperatures are presumed to have been
taken orally unless otherwise noted.
Note: Infants and very small children may be held in
your lap or over your knees for this procedure. Hold the
thermometer and the buttocks with your dominant hand
while securing the child with your nondominant hand.
If the child moves, the thermometer and your hand will
move together, avoiding injury to the anal canal.
Chapter 16 Medical History and Patient Assessment 329
Procedure 16-5 Measuring an Axillary Temperature
1. Gather the following supplies: a glass mercuryfree oral thermometer with a blue top, a disposable probe cover, tissues or cotton balls, disposable
exam gloves, a biohazard waste container, and
disinfectant solution. Then, wash your hands and
put on gloves.
2. Dry the thermometer if it has been stored in a
disinfectant solution. To dry the thermometer, use
tissues or cotton balls to wipe the thermometer
from the bulb up the stem. A dry thermometer will
slip easily into the sheath.
3. Carefully check the thermometer for chips or
cracks. A damaged thermometer could injure the
patient.
4. Check the thermometer reading. Hold the stem at
eye level and turn it slowly to see the liquid in the
column.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4thed. Philadelphia, PA: Wolters
Kluwer; 2013.)
9. Leave the thermometer in place for 10 minutes.
Axillary temperatures take longer than oral or rectal ones. You shouldn’t need to hold the thermometer in place unless the patient does not understand
that the arm must stay down.
P
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Y
5. If the reading is above 94°F, shake down the thermometer. The liquid inside must be below 94°F to
provide an accurate temperature reading.
Grasp the thermometer carefully at the end of
r
the stem using your thumb and forenger.
Snap your wrist several times.
r
Be careful not to hit the thermometer against
r
anything when snapping your wrist.
6. Insert the thermometer into the probe cover. Be
careful not to contaminate the sheath by touching
it or placing it down on any surface.
7. Explain the procedure to the patient. Expose the
patient’s axilla. Do not expose more of the patient’s
chest or upper body than is necessary. It’s important to protect the patient’s privacy at all times.
8. Place the bulb of the thermometer deep in the axilla.
Bring the patient’s arm down, crossing the forearm
over the chest. This position provides thebest skin
contact with the thermometer. It also provides a
closed environment. Drape the patient appropriately for privacy.
10. At the appropriate time, remove the thermometer.
Remove the probe cover by holding the edge of
r
the cover with the thumb and forenger of one
hand and pulling down from the open edge over
the length of the thermometer to the bulb. The
soiled area should now be inside the cover.
Discard the probe cover in a biohazard waste
r
container.
11. Hold the thermometer horizontal at eye level and
note the temperature reading.
12. Sanitize and disinfect the thermometer according to
ofce policy. Then, remove your gloves and wash
your hands.
13. Record the temperature reading in the patient’s
medical record. Be sure to mark an A beside it. This
indicates the reading was axillary. Temperatures
are presumed to have been taken orally unless
otherwise noted.
330 Section IV Clinical Medical Assistant Skills
Procedure 16-6
Measuring Temperature Using an
ElectronicThermometer
1. Gather the following supplies: an electronic
thermometer with an oral or a rectal probe, a disposable probe cover, lubricant, tissues, disposable exam
gloves (for rectal temperature), and a biohazard
waste container. Wash your hands and put on gloves.
2. Greet the patient by name and explain the
procedure.
3. Choose the most appropriate method (oral, axillary,
or rectal). Attach the appropriate probe to the battery-powered temperature unit.
4. Insert the probe into the probe cover. All probes t
into one size probe cover.
Covers usually are carried with the unit in a
r
specially tted box attached to the back of the unit.
If you use the last probe cover, be sure to attach
r
a new box of covers to the unit to be ready for
future patients.
P
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5. Wait for the electronic unit to beep when it senses
that the temperature is no longer rising. This usually occurs within 10 seconds.
6. After the beep, remove the probe. Note the temperature reading on the digital display screen on the unit.
7. Discard the probe cover in a biohazard container
by depressing a button, usually on the end of the
probe. Replace the probe in the slot on the unit, but
make sure you have noted the temperature reading
rst. Most units automatically shut off when the
probe is put back into the unit.
8. Remove your gloves if you are wearing them and
wash your hands. Then, record the temperature in the
patient’s medical record. Record the reading in the
same way as if you were using a glass thermometer.
Indicate a rectal reading with an “R,” an oral reading
with an “O,” and an axillary reading with an “A.”
Procedure 16-7
Measuring Temperature Using a
TympanicThermometer
1. Gather the following supplies: a tympanic thermometer, disposable probe covers, and a biohazard
waste container. Wash your hands.
2. Greet the patient by name and explain the
procedure.
3. Insert the ear probe into the probe cover. Always
put a clean probe cover on the ear probe before
taking a temperature.
4. With your nondominant hand, straighten the
patient’s ear canal. Place the end of the ear probe in
the patient’s ear with your dominant hand.
For most patients, you straighten the ear canal
r
by pulling the top posterior part of the outer ear
up and back.
For children under 3 years of age, pull the outer
r
ear down and back.
P
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(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5thed. Philadelphia, PA: Wolters
Kluwer; 2016.)
5. With the ear probe properly placed in the ear canal,
press the button on the thermometer. The reading will
be shown on the digital display in about 2 seconds.
6. Remove the probe and note the reading. Discard the
probe cover in a biohazard waste container. Probe
covers are for one use only. Then, wash your hands.
7. Record the temperature on the patient’s record in
the same way that you record temperatures for
a glass thermometer. Be sure to indicate that the
tympanic temperature was taken.