Taylor Young

Bryant Stratton College

Subjective and Objective Data

Running Head: SUBJECTIVE AND OBJECTIVE DATA

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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Running Head: SUBJECTIVE AND OBJECTIVE DATA

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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Running Head: SUBJECTIVE AND OBJECTIVE DATA

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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Running Head: SUBJECTIVE AND OBJECTIVE DATA

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.

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