Know What to Ask - Know What to See

By SCMA On 01/03/2017  

Basics of Patient History Interview, Physical Examination and Diagnostics for Medical Assistants

Medical Assistants regularly conduct the patient interview, and take and record both new and established patient health histories. They may conduct certain components of the physical examination to support physicians.¹

Here are a few tips to get the relevant patient history and substantiate it with the physical examination and right investigations.

Patient History Interview

Before the Medical Assistant starts taking the history, she/ he should establish an initial rapport by greeting the patient respectfully and giving a brief introduction.

The history should generally comprise of ²

• patient details
• chief complaint
• past medical and surgical history
• medication records
• personal history- personal history would include social, occupational/travel/family history

And finally before closure, one should give the patient opportunity to ask further questions.

Documentation with correct medical terminology is of paramount importance.

Physical Examination

The general requirements of a physical examination would essentially be

• W - Washing hands
• I - Introduction
• P - Permission
• E - Exposure of the necessary parts for examination.
• R - Repositioning

Vital Signs that need to be routinely measured are:

• temperature
• heart rate
• respiratory rate
• blood pressure
• weight/height

A medical assistant should prepare the examination room taking into account the principles of asepsis.

The physical examination includes in a stepwise manner

• Inspection
• Palpation
• Percussion
• Auscultation

Common Investigations

The primary responsibility of a medical assistant would be the skillful collection of specimens. Most of the investigations fall in the domain of Microbiology, Hematology, Biochemistry etc. and include complete blood count, liver, renal, lipid profile, urinalysis etc.

Radiology would include Chest X-Rays, CT scans, Barium studies, angiography, MRI etc.

Special examinations include Ophthalmology, audiometric examinations, EKG etc.

When conducted properly, the patient interview, the physical examination and the investigations lead to the correct diagnosis.

References

1.Kaplan Medical Assistant Exam Strategies, Practice & Review with Practice Test .5th ed. Kaplan Publishing
2. Doherty M. 2010.Current Diagnosis and Treatment .13thed. United States, Lange Medical Publications