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Subjective and Objective Data
While going to the doctors you have subjective and objective data that needs to be taken
by a medical assistant or nurse. Subjective data includes symptoms, or a complaint that is known
by the patient but cannot be seen or measured by the provider. It is specific, however in relating
the patient’s condition. For example “I have nausea and vomiting for three days”. “I hurt my
ankle yesterday when I tripped over a curb”. Objective data is a manifestation that can be seen,
heard, or measured by any observer. The ankle is visibly swollen and painful to touch. For
example seeing bruising or a bump on the patients head.
Subjective Data
The patient is a 27-year-old male complaining of right lower quadrant abdominal pain,
nausea, and vomiting. The initial onset of the pain was about 48 hours prior to presentation. The
pain was progressive in the nature and began radiating to the back. Late yesterday, the patient
drank some Alka-Seltzer and went to bed. He was awakened during the night by the pain and
began vomiting. The patient states the pain is constant and has localized to the right lower
quadrant. His last bowel movement yesterday afternoon was normal. However he states that this
pain is different than the pain he has had in the past. The Review of Systems are negative except
for complaint of pain in the right lower quadrant.
Objective Data
Past Medical History: Irritable bowel syndrome, last exacerbation six months ago. The
rest of the past medical history is unremarkable.
Past Surgical History: Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia
repair at age four.
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Medications: None.
Allergies: No known drug allergies.
Social History: The patient is employed as a computer programmer. He is married and has no
children. He has smoked a half pack of cigarettes daily for the last ten years. He drinks alcohol
rarely.
Family History: Both parents are alive and well. Other sister has Down syndrome.
General: the patient is an alert, oriented male appearing his stated age. He appears to be in
moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56
degrees C. (101.4 degrees F.)
HEENT: Normocephalic, atraumatic. Pupils were equal, round, reactive to light. Ears clear.
Throat normal.
Neck: The neck is supple with no carotid bruits.
Lungs: The lungs are clear to auscultation and percussion.
Heart: Regular rate and rhythm.
Abdomen: Bowel sounds are normal. There is rebound tenderness, with maximal discomfort on
palpation in the right lower quadrant.
Extremities: No clubbing, cyanosis, or edema.
Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, WBC 13,000. Sodium 138, potassium 3.8,
chloride 105, C02 24, creatinine 0.9, glucose 102. Urinalysis was negative.
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Diagnostic Studies: Flat plate and upright films of the abdomen revealed a localized abnormal
gas pattern in the right lower quadrant with no evidence of free air.
Impression: Appendicitis.
Plan: The Patient will be admitted, kept NPO, and an appendectomy will be performed by Dr.
Rogers in the morning.
Performing Your Responsibilities
It is not always required to be certified as a medical assistant, although it is a good idea to be. It
could determine if you get a job or not. “The CMA (AAMA) sets the standard in medical
assisting certification due to its strict adherence to rigorous educational accreditation,
examination, recertification, and disciplinary policies”. Employers are making it a requirement
to have employees to be certified due to safety reasons. Employers want to be sure medical
assistants know the needed tools and skills needed to work in the office/ workplace. Some
insurance company’s may not insure a practice if the medical assistants are not certified.
“Medical assistants are the only allied health professionals specifically trained to work in
ambulatory care settings, such as physician offices, clinics, and group practices”. Once I have
complete school and become certified, I will be able to prove that I have the knowledge, skills,
and know the tools to become a professional employee in the medical setting (American
Association of Medical Assisting, 2015).
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Reference page
Enjoy the Benefits of Membership! (n.d.) American association of medical assist (AAMA).
Retrieved from http://www.aama-nlt.org./
Lindh, W.Q., Pooler, M.S., Tamparo, C.D., Dahl, B.M., & Morris, J.A. (2014). Delmar’s
comprehensive medical assisting (5th ed.). Clifton Park, NY: Delmar, Cengage Learning.
