Rationale: A patient’s medical condition and body type often need to be taken into consideration during a physical examination. It is typical that during physical assessment, and during certain exams, that the patient will need to be laid flat. Obese patients tend to have particular difficulty in this position for long periods of time. In the recumbent position there is a possibility that the patient will experience difficulty breathing. This is known as orthopnea. If the patient seems to be agitated, anxious, or particularly nervous, pay specific interest in their breathing habit. If the breaths are deep and rapid, there is a high potential for hyperventilation. When the patient is hyperventilating, there is a strong likelihood the patient could experience lightheadedness and even syncope (fainting). The quicker you can recognize the signs of these breathing changes, the quicker they can be remedied to help the patient.
Summarize the history
Rationale: Once you have asked everything in your line of questioning to the patient, it is always critical that you summarize the information that you have taken down. Sometimes lines of questioning can take an extended amount of time. The summary allows you to slowly go through that information with the patient to double-check for accuracy and completion. More often than not, the patient will think of additional information during the summary that they may have overlooked or not even thought of before hand. Taking the extra time to summarize ensures that you are giving the most complete patient history to the physician to optimize the continuity of care to the patient.
Rationale: Certain healthcare providers prefer to have their charting set up with a distinct, regimen method. A popular style for charting is use of the acronym S.O.A.P. Each letter stands for a different aspect of the charting process. They are respectively Subjective, Objective, Assessment, and Plan. Subjective documentation is the portion of the charting where the patient’s history is taken down; everything from the patient’s own description of the ailment, to the medical history, medications, allergies, etc. The mnemonic device S.A.M.P.L.E. can be used in the Subjective step. The Objective portion of the chart is the total physical assessment of the patient. This involves vital signs, lab results, and the physician’s interpretation of the physical status. Assessment is the culmination of the first two steps which allows the physician to make a diagnosis. The Plan is how the physician decides to treat and resolve the patient diagnosis.
Rationale: Cyanosis is a medical condition where the skin begins to take on a bluish or purple tint because of a decrease in oxygen saturation to the tissues. The bluish color comes from the ability to see deoxygenated blood through the mucous membranes, which is far darker than oxygenated blood. This gives us the perception of a bluish tint through the skin. This condition is most easily recognized in the mucous membranes of the body such as the lips and mouth. However, the nail beds are also a good indicator of cyanosis. Certain patients that have a history of difficulty breathing may in fact live with this condition. But, if a patient begins to change into this color, it is critical that they be given oxygen immediately. It is quite possible that a patient could lose consciousness as their oxygen saturation levels begin to drop, so make sure that the cyanotic patient is being monitored on a constant basis for their own protection.
Rationale: Palpation is a commonly used process during the physical examinations of patients. Palpation can be used for a number of different reasons. Physicians tend to use palpation as a way to check the size, shape, texture, consistency and firmness of an internal organ or an area of the body. The most common site on the body for palpation is the abdomen due to the number of internal organs residing in that area. However, palpation can also be used to locate specific internal structures by noting the relationship between anatomical landmarks. For example, the pubic symphysis of the pelvis is a midline structure, and is located in relationship to a line ½ inch above the greater trochanter of the femur. If an x-ray technologist needs to image that specific structure, this saves the modesty of the patient by not having to reach between their legs to palpate the pubis directly. Instead, you only palpate the outer hip area to find that internal structure indirectly.
Rationale: A working diagnosis is a predictable patient condition based on the information available to you at the time. For example, if a patient complains of productive cough, sore throat, and runny nose for 1 week, it is reasonable to assume a working diagnosis of an upper respiratory infection (URI). Working diagnoses can change as new information is brought to light from lab work, blood work, diagnostic imaging, and other alternatives. Once enough information has been collaborated to put together a reasonable overall condition of the patient, it is referred to as a medical diagnosis. A medical diagnosis is an attempt to classify an ailment into a specific category for treatment. For example, a patient has a progressively worsening cough for one month. The physician orders a chest x-ray. The chest x-ray shows an advanced case of pneumonia in the right lung. The physician then makes the medical diagnosis of pneumonia based on the total information presented.
Rationale: Physical assessments are an important part of any examination. They can give great insight into the current status of a patient. Skin temperature is a good indication of what can be happening internally to a patient. A patient that is very ill may present with a pale pallor, cool skin, and may even be diaphoretic (profusely sweating). Diaphoresis can be a telltale sign of shock, anxiety or other severe medical conditions. Perspiration is completely controlled by a person’s autonomic nervous system. This means that the patient has no control over how much they perspire. Because of this, diaphoresis is a valid communication about how hard a patient’s body is fighting to cool down the patient’s internal temperatures. If a patient’s skin is hot but dry, this could possibly indicate a fever. Warm and moist is typically considered to be a normal skin condition.
Rationale: A useful mnemonic device was created to assist in taking patient histories. The mnemonic device is S.A.M.P.L.E. “S” stands for Signs and Symptoms. This is mostly a visual assessment taken during a patient history. “A” stands for Allergies. It is critical to gain knowledge about a patient’s allergic reactions to medications. If a physician is not alerted prior to prescribing medication, a catastrophic error could be made. “M” stands for Medications. Always take a list of what medications the patient is currently taking to avoid possible replication with the physician’s prescriptions. “P” is Past medical history. A complete medical history is important to understand how previous ailments could affect the current condition. “L” stands for Last oral intake. This could alter the types and amounts of medications given to the patient. “E” stands for events leading up to the injury/illness. This assists the physician in understanding the patient’s total medical situation.
Rationale: When taking a patient history, it is important to allow the patient to give you as much unbiased information as possible. So, at the beginning of a patient history, make sure to ask open-ended questions. These are questions that don’t lead the patient in any one direction, but instead, allow the patient to fill in as many details as they can. For example, “How long have you had that cough?” or, “How long has your abdomen hurt like this?” Once this style of questioning has become exhausted, then you can begin to tighten down the questions by giving the patient options. Such as, “Do you cough more in the morning or at night?” or, “Does your abdomen hurt after you eat, before, or all the time?” These styles of questions begin leading the patient on certain paths in an attempt to fill in the gaps of your patient history. Try to avoid yes/no questions, as they do not give a lot of information, and simply act as a process of elimination.
Rationale: During patient assessment, it is typical for physicians to listen to different parts of the body to gauge the response of internal organs. This process is known as auscultation. Auscultation is typically performed using a stethoscope to listen to the lungs (to rule out fluid or wheezing), heart (to rule out heart murmurs), and peristalsis within the bowel. The physicians pay particular attention to the intensity of the sounds, the frequency, and the duration. But physicians have been known to use Doppler ultrasound as well. With certain patient conditions, it can be difficult to find a pulse through touch and record a patient’s heart rate. Through the use of Doppler ultrasound, the physician will typically listen to either the radial or pedal pulse for the heart rate.